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Auto Quote Form


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
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Last Name
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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Alternate Phone Number
Optional
E-Mail Address
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Social Security Number
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Date of Birth
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/ /
Marital Status
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Do you currently have insurance?
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Current Insurance Provider
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If no, when did you last have insurance?
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Are all vehicles registered in your name?
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Do you rent or own your home?
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Driver Information
Name of Driver (First, Last)
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Date of Birth
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/ /
License (State, Number)
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Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)?
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Additional Driver Information
Name of Driver (First, Last)
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Date of Birth
Required
/ /
License (State, Number)
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Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)?
Optional
Vehicle Information
Vehicle #1
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Vehicle 1 VIN
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Comprehensive Deductible
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Collision Deductible
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Drive vehicle 1 to school or work?
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How many miles will you drive your car annually? (Approximately)
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Lien Holder
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Vehicle #2
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Vehicle 2 VIN
Optional
Comprehensive Deductible
Optional
Collision Deductible
Optional
Drive vehicle 2 to school or work?
Optional
How many miles will you drive your car annually? (Approximately)
Optional
Lien Holder
Optional
Vehicle #3
Optional


Vehicle 3 VIN
Optional
Comprehensive Deductible
Optional
Collision Deductible
Optional
Drive vehicle 3 to school or work?
Optional
How many miles will you drive your car annually? (Approximately)
Optional
Lien Holder
Optional
Coverage Options
Bodily Injury Liability
Required
Property Damage Liability
Required
Uninsured Motorist Bodily Injury
Optional
Underinsured Motorist - Bodily Injury Limits
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Medical Pay / PIP
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Towing
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Rental
Optional
Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

Valley Agency Company
(717) 264-4311
797 Fifth Avenue - Chambersburg, PA 17201
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