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E-Mail:
quotes@lowcost
insurancekentucky.com

Office Phone Number:
859-233-1637

Fax Number:
859-254-3753

Office Address:
635 N Broadway
Lexington, KY 40508

Sullivan Insurance Agency
Since 1962

Website Design © 2009
Ins. Web Sales, Inc.



 

Immediate Telephone Quotes Here:
Call us for a free Kentucky auto insurance quote!
Or, Complete the Simple 2-Minute Form Below!



On-Line Automobile
Insurance Quote Form
for D.U.I. (DWI) Drivers
One Simple Form - takes only 2-3 Minutes!

We know how you may feel about your major citation... we will do everything we can to make you feel comfortable, and to assure that your insurance is as low cost as possible!


Your Personal Data

Your Name:
Street Address:
City:
Your "County" is?
State: (Must be Kentucky)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
Primary Policyholder's Occupation:


DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Drivers License Number:
(Required for Discounts)
In Military or
Coast Guard?
Yes No
Pay Grade E4/Lower
or E5/Higher?
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No If YES to DL123 filing, why needed?
(list accident/cite)


DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Drivers License Number:
(Required for Discounts)
In Military or
Coast Guard?
Yes No
Pay Grade E4/Lower
or E5/Higher?
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No Comments or
Remarks?


VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of
Liability:
$25/50 BI / 10 PD $50/100 BI / 50 PD
$100/300 BI / 50 PD $250/500 BI / 100 PD
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical/PIP Coverage?
Yes No   Uninsured
  Motorists Cov.?
Yes No
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of
Liability:
$30/60 BI / 25 PD $50/100 BI / 50 PD
$100/300 BI / 50 PD $250/500 BI / 100 PD
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?
Yes No   Uninsured
  Motorists Cov.?
Yes No
Comments or Remarks:
(List additional drivers, autos, etc. here)


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Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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