Phone: 606-474-5128
Fax: 606-474-5001
Email: info@millerins.net
Hours: Mon-Fri 9-5pm, Sat: 9-12pm
210 South Carol Malone Blvd
Grayson, KY 41143

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Auto Insurance

Personal Information
Name
Address
City
State
Zip Code
Day Phone
Evening Phone
Best Time to Call
Email Address
Current Auto Insurance Information
Company Name (not agency)
Policy Expiration Date
Premium Amount $
Term 6 Months 1 Year
Vehicle Information
Year
Make
Model
Body Type
VIN
Name of Title Holder
Annual Mileage
Drive to School/Work?
Yes No
Number of Miles
Airbags Yes No Car Alarm Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Location City
State
Zip Code
Liability Limit
Choose either Bodily Injury and Property Damage -or- Single Limit
Bodily Injury
Property Damage
or Single Limit
Deductibles and Misc.
Comprehensive Deductible
Collision Deductible Towing
Yes
Loss of Use
Yes
Driver Information
Driver's Name
License #
State
Years Licensed
Date of Birth
Sex
M F
Marital Status
Married Single
Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Please list ANY driver who has had license suspensions, revocations or DUI convictions below
Please list ANY driver involved in accidents, regardless of fault, in the past 5 years
Additional Information
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.
Permission to Obtain Consumer Reports
To provide an accurate quote, we have asked you a series of questions some of which we will confirm through consumer reports, which may include credit, motor vehicle and loss information reports. This information will be available to our companies with whom we will obtain your quote.
Is it O.K. to continue?
Yes No
Fraud Statement
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
I have read the above Fraud Statement
Yes No

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