Carrier Insurance Agency
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(814) 226-6580

Toll-free: (800) 822-9486

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Get an Auto Insurance Quote

   Fill out the information below, and one of our representatives will contact you shortly with an accurate auto insurance quote.

   For more information on our policies, feel free to call one of our friendly representatives at (814) 226-6580 or toll-free at (800) 822-9486.


Policy Holder Information
First Name*   Last Name*  
Address*
City*   State*  
County   Zip Code*  
Email*
Work Phone   Home Phone*  
Age   Birth Date
Years Licensed   Driver's License Number
Do you have any additional insurance policies with our agency?
Yes No
Number of Drivers?*
One Two Three Four Five
Primary Driver Information
First Name*   Last Name*  
Age*   Birth Date*
Licensing State*   Gender*
Marital Status*  
 
List any moving violations or accidents from the past three years:*
   
 
Driver 2 Information
First Name*   Last Name*  
Age*   Birth Date*
Licensing State*   Gender*
Marital Status*  
 
List any moving violations or accidents from the past three years:*
   
 
Driver 3 Information
First Name*   Last Name*  
Age*   Birth Date*
Licensing State*   Gender*
Marital Status*  
 
List any moving violations or accidents from the past three years:*
   
 
Driver 4 Information
First Name*   Last Name*  
Age*   Birth Date*
Licensing State*   Gender*
Marital Status*  
 
List any moving violations or accidents from the past three years:*
   
 
Driver 5 Information
First Name*   Last Name*  
Age*   Birth Date*
Licensing State*   Gender*
Marital Status*  
 
List any moving violations or accidents from the past three years:*
   
 
 
Fields marked * are mandatory
Auto Underwriting Questions
The following questions are for all members of the household and for anyone whom operates your vehicles.
1. Has any driver, member of the household, or anyone who operates your vehicles been refused, cancelled, or non-renewed auto insurance in the past three years?*
  Yes     No
  If yes, please list the company name, reasoning, and date.
 
2. Has any driver, member of the household, or anyone who operates your vehicles had their driver's license revoked or suspended in the past three years?*
  Yes     No
  If yes, please list the driver's name, date revoked, and reason for suspension.
 
3. Has any driver, member of the household, or anyone who operates your vehicles received a ticket for speeding?*
  Yes     No
  If yes, please list the driver's name, date of the ticket, the violation, the speed, and the zone of the violation.
 
4. Has any driver, member of the household, or anyone who operates your vehicles receieved a ticket for any additional moving violations in the past three years?*
  Yes     No
  If yes, please list the driver's name, date of the ticket, and the violation.
 
5. Has any driver, member of the household, or anyone who operates your vehicles been arrested for any reason?*
  Yes     No
  If yes, please list the driver's name, date of the arrest, and the reason.
 
6. Has any driver, member of the household, or anyone who operates your vehicles file a claim such as deer, fire, theft, or windshield?*
  Yes     No
  If yes, please list the driver's name, type of the loss, the date, and the dollar value of the claim.
 
7. Has any driver, member of the household, or anyone who operates your vehicles been in an accident whether they were at fault or not in the past three years?*
  Yes     No
  If yes, please list the driver's name, the date, a description of the accident, and the dollar value of the claim.
 
 
Fields marked * are mandatory.
Vehicle Information
How many vehicles would you like to insure?* One Two Three Four Five
Are all the vehicles listed on this policy titled to the same name?* Yes     No    
 
Vehicle 1
Vehicle Make*   Vehicle Model*  
Vehicle Year*   Vehicle VIN*  
How is the Vehicle Titled?*  
Licensed State?*  
Vehicle's Primary Purpose?*
Work Pleasure Business
Annual mileage to Work/School (one way)*  
Annual mileage for Pleasure Purposes*  
Annual mileage for Business Purposes*  
 
Vehicle 2
Vehicle Make*   Vehicle Model*  
Vehicle Year*   Vehicle VIN*  
How is the Vehicle Titled?*  
Licensed State?*  
Vehicle's Primary Purpose?*
Work Pleasure Business
Annual mileage to Work/School (one way)*  
Annual mileage for Pleasure Purposes*  
Annual mileage for Business Purposes*  
 
Vehicle 3
Vehicle Make*   Vehicle Model*  
Vehicle Year*   Vehicle VIN*  
How is the Vehicle Titled?*  
Licensed State?*  
Vehicle's Primary Purpose?*
Work Pleasure Business
Annual mileage to Work/School (one way)*  
Annual mileage for Pleasure Purposes*  
Annual mileage for Business Purposes*  
 
Vehicle 4
Vehicle Make*   Vehicle Model*  
Vehicle Year*   Vehicle VIN*  
How is the Vehicle Titled?*  
Licensed State?*  
Vehicle's Primary Purpose?*
Work Pleasure Business
Annual mileage to Work/School (one way)*  
Annual mileage for Pleasure Purposes*  
Annual mileage for Business Purposes*  
 
Vehicle 5
Vehicle Make*   Vehicle Model*  
Vehicle Year*   Vehicle VIN*  
How is the Vehicle Titled?*  
Licensed State?*  
Vehicle's Primary Purpose?*
Work Pleasure Business
Annual mileage to Work/School (one way)*  
Annual mileage for Pleasure Purposes*  
Annual mileage for Business Purposes*  
 
 
Fields marked * are mandatory.
Current Insurance
Do you currently have insurance coverage? Yes    No
Company Name:   Renewal Date:  
Annual Premium:  
 
Current Coverages
Tort Option: Full    Limited
Bodily Injury Liability:
15/30 100/300
25/50 250/500
50/100 Other
Other
Property Damage Liability:
$5,000 $50,000
$10,000 $100,000
$25,000 $250,000
Other
Other
Medical Expenses:
$5,000 $50,000
$10,000 $100,000
$25,000 Other
Other
Income Loss:
1,000/5,000 2,500/50,000
1,000/15,000 5,000/100,000
1,500/25,000 Waived
Accidental Death:
$5,000 $10,000 $25,000
Funeral:
$1,500 $2,500 Waived
 
Uninsured Motorists
Stacked:
15/30 100/300
25/50 250/500
Unstacked:
50/100
Limits:
 
Underinsured Motorists
Stacked:
15/30 100/300
25/50 250/500
Unstacked:
50/100
Limits:
 
Other Options
Comprehensive
Deductible:
  Collision
Deductible:
 
Road Service/Towing:   Rental
Reimbursement
 
 
How Did You Hear About Us?
 
Fields marked * are mandatory.
**Please note that this quote is not final until an agent contacts you**

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Location

Carrier Insurance Agency
21823 Rt. 68 Suite 3
Clarion, PA 16214
Phone: (814) 226-6580
Toll-Free: (800) 822-9486
Fax: (814) 226-8514

Email: carrierinsagencyinc@hotmail.com
Directions
(in front of Tractor Supply)

Office Hours

Monday - Friday: 8:00 AM - 5:00 PM

Companies We Represent
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