Classic Car Quote Request

Insurance for your pride and joy

Would you like to receive a free quote? Please fill in the information below. We will contact you as soon as possible.

Personal Information:

Name
Street address
City
State
Zip/Postal code
Work Phone
Home Phone
FAX
E-mail
Best Time to
contact you
Do you have other
daily transportation?

Yes
No

 Liability on your regular use vehicle?

Minimum
100,000
300,000
100k-300k
500,000
Other

Auto information:

Auto #1

Year
Make
Model
Value $
Condition?

Fair
Good
Excellent

 Modified from original?

Yes
No

 Garaged ?

Yes
No

Auto #2

Year
Make
Model
Value $
Condition?

Fair
Good
Excellent

 Modified from original?

Yes
No

 Garaged?

Yes
No

Auto #3

Year
Make
Model
Value $
Condition?

Fair
Good
Excellent

 Modified from original?

Yes
No

 Garaged?

Yes
No

Comments?

W-B Insurance does NOT sell, lend, rent, exchange or give away customer information to third parties.The information you have provided will be used to prepare a quote for you and is subject to the company's review and approval.  This is NOT an insurance policy or binder!


This page was last updated on July 17, 2003 by R. Wright. Please report problems or errors to me at webmaster@wbins.com. While I make every attempt that information be complete and accurate, I cannot be liable for decisions based on these page contents.