Statewide Insurance Agency
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(405) 285-2929
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Auto Insurance Quote Form
Step 1 of 19
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Enter your ZIP code
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How did you hear about Statewide Insurance Agency?
I was referred by another person
Internet search
I received a letter or postcard
Social media or internet ad
Who referred you?
Existing Policy Information
Do you currently have auto insurance?
Yes
No
You have indicated that you do not currently have insurance. If your coverage lapsed less than 30 days ago, we can offer a preferred quote to you. If you have not had coverage in the last 30 days, we will not be able to offer a quote and apologize for any inconvenience.
When does your existing policy expire?
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1921
1920
How many vehicles are we quoting?
1
2
3
4
5
6
How many drivers are in your household?
1
2
3
4
5
6
Primary Vehicle
Year
Make
Model
Trim
Airbags
4
2
Primary Use
Business
Pleasure
Work
Farm
Deductibles
Comprehensive
100
250
500 (most common)
1000
No Coverage
Collision
100
250
500 (most common)
1000
No Coverage
Second Vehicle
Year
Make
Model
Trim
Airbags
4
2
Primary Use
Business
Pleasure
Work
Farm
Deductibles
Comprehensive
100
250
500 (most common)
1000
No Coverage
Collision
100
250
500 (most common)
1000
No Coverage
Third Vehicle
Year
Make
Model
Trim
Airbags
4
2
Primary Use
Business
Pleasure
Work
Farm
Deductibles
Comprehensive
100
250
500 (most common)
1000
No Coverage
Collision
100
250
500 (most common)
1000
No Coverage
Fourth Vehicle
Year
Make
Model
Trim
Airbags
4
2
Primary Use
Business
Pleasure
Work
Farm
Deductibles
Comprehensive
100
250
500 (most common)
1000
No Coverage
Collision
100
250
500 (most common)
1000
No Coverage
Fifth Vehicle
Year
Make
Model
Trim
Airbags
4
2
Primary Use
Business
Pleasure
Work
Farm
Deductibles
Comprehensive
100
250
500 (most common)
1000
No Coverage
Collision
100
250
500 (most common)
1000
No Coverage
Sixth Vehicle
Year
Make
Model
Trim
Airbags
4
2
Primary Use
Business
Pleasure
Work
Farm
Deductibles
Comprehensive
100
250
500 (most common)
1000
No Coverage
Collision
100
250
500 (most common)
1000
No Coverage
Primary Driver
Full Legal Name
First
Middle
Last
Suffix
Birthday
Month
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1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Marital Status
Married
Unmarried
Driver's Liscense State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Drivers License Number (if available)
Age you first receieved your license
Second Driver
Full Legal Name
First
Middle
Last
Suffix
Birthday
Month
1
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5
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9
10
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12
Day
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Marital Status
Married
Unmarried
Driver's Liscense State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Drivers License Number (if available)
Age you first receieved your license
Third Driver
Full Legal Name
First
Middle
Last
Suffix
Birthday
Month
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12
Day
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Year
2019
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2015
2014
2013
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2009
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Marital Status
Married
Unmarried
Driver's Liscense State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Drivers License Number (if available)
Age you first receieved your license
Fourth Driver
Full Legal Name
First
Middle
Last
Suffix
Birthday
Month
1
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3
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5
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10
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12
Day
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Year
2019
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2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1940
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Marital Status
Married
Unmarried
Home ownership status
Own
Rent
Other
Driver's Liscense State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Drivers License Number (if available)
Age you first receieved your license
Fifth Driver
Full Legal Name
First
Middle
Last
Suffix
Birthday
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
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10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Marital Status
Married
Unmarried
Home ownership status
Own
Rent
Other
Driver's Liscense State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Drivers License Number (if available)
Age you first receieved your license
Sixth Driver
Full Legal Name
First
Middle
Last
Suffix
Birthday
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Marital Status
Married
Unmarried
Home ownership status
Own
Rent
Other
Driver's Liscense State of Issue
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Drivers License Number (if available)
Age you first receieved your license
Please tell us about all moving violations, all accidents and all claims within the last 3 years. Please include at-fault as well as non-fault accidents and also include claims for acts of nature (ie, wind & hail damage)
Current Coverage
How long have you been with this company?
Years
Months
How many years of continuous automobile insurance coverage have you had?
Years
Months
What liability insurance limits do you now have with your current insurance company? (in thousands)
25/50/25
50/100/50
100/300/100
250/500/100
Other or not sure
New Policy Information
Tell us what coverage's to quote
Liability Insurance Limits? (in thousands)
25/50/25
50/100/50
100/300/100
250/500/100
Other or not sure
Uninsured motorist? (in thousands)
25/50
50/100
100/300
250/500
Other
Medical Payments Coverage?
1,000
5,000
10,000
50,000
Rental Reimbursement (Per Day)
$30
$50
Towing / Roadside Assistance
Yes
No
Getting Your Quote
Full Legal Name
First
Middle
Last
Suffix
Spouse or Co-Applicants Legal Name (if applicable)
First
Middle
Last
Suffix
Current Home Address
Street Address
Apt/Suite/Bldg
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Ownership
Own
Rent
Other
Primary Phone
Secondary Phone (optional)
Email Address
Tell us how and when to contact you
How would you like for us to contact you?
Telephone Only
Email Only
Telephone and/or Email
When would you like for us to contact you?
Please rush it!
As soon as you have it ready (usually one half day)
Request another time
When would be a good time for us to contact you?
Comments/Additional Information
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