Platte Valley Insurance Agency - Elm Creek, Nebraska


	308-856-4913


	Below is the form we provide for an automobile insurance quote. We appreciate the time it takes to fill in the information. If you would rather not take the time required to do this online, but desire an agent to contact you, click here.

REQUEST for an AUTOMOBILE INSURANCE QUOTE

Thanks for your interest in an automobile insurance quote from Platte Valley Insurance Agency. To receive an insurance quote, fill out form below. Please notice fields marked with '*' are required to be filled in prior to submission. Any questions or further information can be typed into the comments box. We respect your privacy and will use the information for only the purpose you sent it. We thank you in advance for your interest and time. All inquiries will be considered and responded to.

Personal and Garage Information:
Your Full Name:*
Your Garage Address:*
City, State Zip:*
Your Mailing Address:*
City, State Zip:*
Telephone Number:*
Fax Number
Email Address:
Driver Information:
DRIVER #1
Driver #1 Full Name:*
Driver #1 Gender:*
Driver #1 Years Licensed:*
Driver #1 State Licensed In:*
Driver #1 License Number:*
Driver #1 Occupation:*
Driver #1 Date of birth:*
Marital Status:*
DRIVER #2
Driver #2 Full Name:
Driver #2 Gender:
Driver #2 Years Licensed:
Driver #2 State Licensed In:
Driver #2 License Number:
Driver #2 Occupation:
Driver #2 Date of birth:
Marital Status:
DRIVER #3
Driver #3 Full Name:
Driver #3 Gender:
Driver #3 Years Licensed:
Driver #3 State Licensed In:
Driver #3 License Number:
Driver #3 Occupation:
Driver #3 Date of birth:
Marital Status:
DRIVER #4
Driver #4 Full Name:
Driver #4 Gender:
Driver #4 Years Licensed:
Driver #4 State Licensed In:
Driver #4 License Number:
Driver #4 Occupation:
Driver #4 Date of birth:
Marital Status:
Vehicle Information:
VEHICLE #1
Year of Vehicle #1:
Make of Vehicle #1:
Model of Vehicle #1:
VIN of Vehicle #1:
Miles per Year of Vehicle #1:
Use of Vehicle #1:
Number of miles one way:
Driver Side Air Bags?		Yes No
Dual Air Bags?		Yes No
Automatic Seat Belts?		Yes No
Anti-Lock Brakes?		Yes No
Anti-Theft Device?		Yes No
Ownership Status of Vehicle #1:
VEHICLE #2
Year of Vehicle #2:
Make of Vehicle #2:
Model of Vehicle #2:
VIN of Vehicle #2:
Miles per Year of Vehicle #2:
Use of Vehicle #2:
Number of miles one way:
Driver Side Air Bags?		Yes No
Dual Air Bags?		Yes No
Automatic Seat Belts?		Yes No
Anti-Lock Brakes?		Yes No
Anti-Theft Device?		Yes No
Ownership Status of Vehicle #2:
VEHICLE #3
Year of Vehicle #3:
Make of Vehicle #3:
Model of Vehicle #3:
VIN of Vehicle #3:
Miles per Year of Vehicle #3:
Use of Vehicle #3:
Number of miles one way:
Driver Side Air Bags?		Yes No
Dual Air Bags?		Yes No
Automatic Seat Belts?		Yes No
Anti-Lock Brakes?		Yes No
Anti-Theft Device?		Yes No
Ownership Status of Vehicle #3:
VEHICLE #4
Year of Vehicle #4:
Make of Vehicle #4:
Model of Vehicle #4:
VIN of Vehicle #4:
Miles per Year of Vehicle #4:
Use of Vehicle #4:
Number of miles one way:
Driver Side Air Bags?		Yes No
Dual Air Bags?		Yes No
Automatic Seat Belts?		Yes No
Anti-Lock Brakes?		Yes No
Anti-Theft Device?		Yes No
Ownership Status of Vehicle #4:
Violation Information:
Last 3 years (minor violations) Last 5 years (major violations)
		Driver 1	Driver 2		Driver 3	Driver 4
Minor violations - speeding, turning, stop sign, stop light, etc.*
Accidents - non chargeable*
Accidents - chargeable*
Major violations - drunk driving, reckless, hit and run, etc.*
Coverage Information:
	Bodily Injury			Property Damage
Personal Liability
Uninsured/Underinsured Motorist
Medical Payment
Accidental Death Benefits
Deductible Information:
		Vehicle 1	Vehicle 2		Vehicle 3	Vehicle 4
Comp*
Collision*
Miscellaneous Information:
Current Insurance Company:
Policy Expiration Date:
Current Premium:
How would you rate your credit?
Comments or Questions for Platte Valley Insurance Agency?


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Platte Valley Insurance Agency
121 North Tyler P.O. Box 625 Elm Creek, Nebraska 68836	308-856-4913 308-856-4490 308-233-4892
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