Garner Insurance Concepts Call or TEXT 801.298.5977
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About Us
NOTE:
NO coverage is bound until you are contacted by one of
our
representatives.
It is helpful if you have a copy of your current insurance declaration page when filling in the following fields.
Contact Information:
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Indicates required field
Name
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First
Last
Address
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City
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State
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Zip Code
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Phone Number
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Email
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Driver Information:
Driver #1:
Name: Last, First
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Date of Birth
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Gender:
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Male
Female
Marital Status:
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Married
Single
Distance to work:
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< 15 Miles
16 - 20 Miles
21 - 25 Miles
> 26 Miles
Tickets or Accident in the last 3 years?
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Yes
No
If Yes, Please Explain:
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Driver #2:
Name: Last, First
*
Date of Birth:
*
Gender:
*
Male
Female
Marital Status:
*
Married
Single
Distance to work:
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< 15 Miles
16 - 20 Miles
21 - 25 Miles
> 26 Miles
Tickets or Accidents in the last 3 years?
*
Yes
No
If Yes, Please Explain:
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Driver #3:
Name: Last, First
*
Date of Birth:
*
Gender:
*
Male
Female
Marital Status:
*
Married
Single
Distance to work:
*
< 15 Miles
16 - 20 Miles
21 - 25 Miles
> 26 Miles
Tickets of Accidents in the last 3 years?
*
Yes
No
If yes, Please Explain:
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Driver #4:
Name: Last, First
*
Date of Birth:
*
Gender:
*
Male
Female
Marital Status:
*
Married
Single
Distance to work:
*
< 15 Miles
16 - 20 Miles
21 - 25 Miles
> 26 Miles
Tickets or Accident ins the last 3 years?
*
Yes
No
If Yes, Please Explain:
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Do you or anyone in your household consume alchohol?
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Yes
No
Vehicle Information:
Vehicle #1
Year:
*
Make:
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Model:
*
VIN Number:
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Vehicle #2
Year:
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Make:
*
Model:
*
VIN Number:
*
Vehicle #3
Year:
*
Make:
*
Model:
*
VIN Number:
*
Vehicle #4
Year:
*
Make:
*
Model:
*
VIN Number:
*
Coverages:
Bodily Injury:
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$50,000/$100,000
$25,000/$50,000
$100,000/$300,000
Other
SelProperty Damage:
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$50,000
$25,000
$100,000
Other
Comprehensive Deductible:
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None
$1000
Other
Collision Deductible:
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None
$1000
Other
Towing/Rental/Glass
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Yes
No
Glass Deductible
$100
$200
Other
Coverage on Vehicle #2:
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Full Coverage
Liability Only
Coverage on Vehicle #3:
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Full Coverage
Liability Only
Coverage on Vehicle #4:
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Full Coverage
Liability Only
Note: All liability limits must match each vehicle, Deductibles CAN be different.
Current Insurance Provider:
Insurance Provider:
*
Insured Period:
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Semi-Annual (6 mo. term)
Annual (12 mo. term)
Permium:
*
Additional Information:
Currently Renting/Own your home/Other
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Own your own home
Rent
Other
Agent
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L. Lee Garner
Clint L. Garner
Kenzie Landvatter
Were you REFERRED by a Friend or Family Member? Please tell us who so we can send them a THANK YOU!
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How would you like to be contacted?
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Email
Phone
Mail
Submit
