Auto Insurance Quote

Want a quote for Auto Insurance? Please fill out this form as completely as possible.
Fields with "*" are required. Click "Send to Lenz" when you are finished.
We'll respond by the next business day. Thank you!

About You
Name*
Email Address*
Mailing Address*
Street Address
(if different from mailing address)
City*
State*
Zip Code*
Phone Number*
Home Status
If Less Than 1 Year At This Address,
Enter Previous Address

About Your Present Insurance
Do You Currently Have Auto Insurance? Yes    No  
If No, Why Not?
If No, How Long Without Insurance?
If Yes, Carrier Name
If Yes, Policy Expiration Date
If Yes, Current Bodily Injury Limits
Do You Currently Have Health Insurance? Yes    No  
If Yes, Does It Cover
Auto Accidents?		 Yes    No
If Yes, Carrier Name
Are You Associated With Any Groups, Colleges or Credit Unions? Yes    No  
If Yes, Describe
Do You Drive a Company Car? Yes    No  

About Your Household Members
(please include yourself)
Name
 Driver's
License #
 Date of
Birth
 Employer/
Occupation
Tickets
Accidents
Miles
to Work
1
2
3
4
5
If Tickets or accidents, please describe with amounts paid:

About Your Vehicle(s)
Year Make Model VIN# Driven By
Vehicle 1
Special Considerations (check those that apply)
ABS Brakes Anti-Theft System Alarm System
Single Air Bag Dual Air Bags Side Air Bags

Year Make Model VIN# Driven By
Vehicle 2
Special Considerations (check those that apply)
ABS Brakes Anti-Theft System Alarm System
Single Air Bag Dual Air Bags Side Air Bags

Year Make Model VIN# Driven By
Vehicle 3
Special Considerations (check those that apply)
ABS Brakes Anti-Theft System Alarm System
Single Air Bag Dual Air Bags Side Air Bags

Year Make Model VIN# Driven By
Vehicle 4
Special Considerations (check those that apply)
ABS Brakes Anti-Theft System Alarm System
Single Air Bag Dual Air Bags Side Air Bags

About Coverages You Want
Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Coverage Type PL/PD (Liability)
Coverage Only
Full Coverage
 PL/PD (Liability)
Coverage Only
Full Coverage
 PL/PD (Liability)
Coverage Only
Full Coverage
 PL/PD (Liability)
Coverage Only
Full Coverage
Liability Limits
(all vehicles)
Comprehensive Deductible
Full Glass
Collision Deductible
Road Service?
Rental?
Loan/Lease Gap Insurance?

How Should We Communicate With You
and Provide Your Quote?
Please email me
Please telephone me



Thank you!
Please feel free to contact us with questions or for a quote anytime.

Ludington, 231-845-6279
Zeeland, 616-748-9440
Muskegon, 231-739-6300