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Contact Us
Perryton Office
(806) 435-3625
Booker Office
(806) 658-4528
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Enter Your Information Here:
*
Indicates required field
Vehicle #1:
Year
*
Make
*
Model
*
Annual Mileage
*
5,000
7,500
10,000
12,500
15,000
20,000
25,000
30,000
40,000
50,000+
Collision Deductible
*
$100
$250
$500
$1000
No Coverage
Is Vehicle Leased?
*
Yes
No
Comprehensive Deduct
*
$100
$250
$500
$1000
No Coverage
Vehicle #2 (if necessary)
Year (V2)
*
Make (V2)
*
Model (V2)
*
Annual Mileage (V2)
*
5,000
7,500
10,000
12,500
15,000
20,000
25,000
30,000
40,000
50,000+
Collision Deduct. (V2)
*
$100
$250
$500
$1000
No Coverage
Is Vehicle Leased? (V2)
*
Yes
No
Comp Deduct. (V2)
*
$100
$250
$500
$1000
No Coverage
Driver Information
Primary Driver Name
*
Gender
*
Male
Female
n/a
Age
*
Under 16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
91-95
96-100
100+
Married?
*
Yes
No
Status
*
Employed
Student
Retired
Other
Driver 2 Name (if necessary)
*
Gender (D2)
*
Male
Female
n/a
Age (D2)
*
Under 16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
91-95
96-100
100+
Married? (D2)
*
Yes
No
Status (D2)
*
Employed
Student
Retired
Other
Current or Prior Insurance Company
*
Continuous Coverage
*
Not Currently Insured
Under 6 Months
6 Months
12 Months
1 Year
2 Years
3 Years
3-5 Years
5-10 Years
10+ Years
Claims in 3 Years
*
None
1
2
3
4+
Policy Expires In
*
Not Sure
A few days
2 weeks
1 month
2 months
3 months
3-6 months
6+ months
Tickets in 3 Years
*
None
1
2
3
4
5
6+
Coverage Desired
*
State Minimum
Standard Coverage
Premium Coverage
Contents Coverage Desired
*
None
$1000
$2000
$3000
$4000
$5000
$7500
$10,000+
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
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Country
Email
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Phone Number
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Message
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