Wheeler Agency, Inc. 
(651) 766-7867 
or toll free: 1-888-765-2554
 
Auto Quote 
This is a quote request form. Submitting this form does not
represent coverage or binding of coverages of any kind. 
By submitting this form you agree to the above statement. 

Location Information

First Name
Last Name
Address
City
County
State
Zip Code
Home Phone
Work Phone
Cell Phone
Email

General Information

Are you currently insured? Yes No
If insured, Company name
Policy Expiration Date
Are you a AAA Member? Yes No
Do you have an insurance policy on a home, condo, or mobile home that you own? Yes No
If you are a renter, do you have a renters insurance policy? Yes No

Policy Wide Liability Coverages

Bodily Injury (BI)
Property Damage (PD)
Or Combined Single Limits
Uninsured/Underinsured Motorists
Personal Injury Protection (PIP) Basic Yes No
If increased, fill in amount
Stacked Yes No

Vehicle Information

Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Year of Vehicle
Make of Vehicle
Model of Vehicle
VIN/Serial #
Is this a leased vehicle
Yes No Yes No Yes No Yes No
Do you carry Comprehensive Coverage on this vehicle?
Yes No Yes No Yes No Yes No
If Yes, enter deductible amount
$ $ $ $
with Full glass coverage?
Yes No Yes No Yes No Yes No
Do you carry Collision Coverage on this vehicle?
Yes No Yes No Yes No Yes No
If Yes, enter deductible amount
$ $ $ $
If you carry Towing, enter amount
$ $ $ $
If you carry Rental Reimbursment, enter amount
$ $ $ $
Do you carry Lease Gap Coverage?
Yes No Yes No Yes No Yes No
If vehicle is a pick-up, is there a camper or topper?
Yes No Yes No Yes No Yes No
If Yes, enter value of camper/topper
$ $ $ $
If vehicle is a conversion van enter value of additions
$ $ $ $

Driver Information

Driver 1 Driver 2 Driver 3 Driver 4

Name

Date of Birth
Gender
Drivers License Number
Social Security Number (Optional)
Marital Status
Relation
Occupation or Student
Vehicle driven
Vehicle # Vehicle # Vehicle # Vehicle #
Usage
If driven to work or school, miles one way
Miles Driven Per Year

Driving Record

Going back 5 years, has any driver had a ticket or accident?Yes List detailsNo
Any other claims such as towing, windshield? Yes List details No
For any driver 55 years or older, has defensive driver course been taken?
Yes No Yes No Yes No Yes No
For any driver who is a student, does he/she have a B average or better?
Yes No Yes No Yes No Yes No
Comments
Name of Your Group
Credit Union
Bank
Association
Other
A report will be ordered on your credit history from a consumer reporting agency for use in determining an insurance score. This insurance score will be used to underwrite and/or rate your insurance policy. The better the score, the lower your insurance premium. The inquiry will not affect your credit history in any way. We are committed to respecting your privacy and safeguarding your personal information. Please acknowledge that you have read and understand this message. Yes