Home
About Us
Our Insurance Companies
Quick Quote
Free Quotes
Automobile
Boat
Condominium
Flood
Homeowners
Manufactured Homes
Motorcycle
Motorhome
Renters
Umbrella
Personal Insurance
Business Owners Policy
Commercial Vehicles
Workers Compensation
Business Insurance
Testimonials
FAQ
Customer Service
Make A Payment
Claims
Business Referral List
Articles
Glossary
Life Stages
Links
Miscellaneous
Insurance Resources
Contact Us
Write a Review
Site Map

Not A Customer Yet? 
Click Here to find out why you should be!

Business Auto Quote 
Commercial Auto Insurance Quote

Contact Information
Contact Name:
Day Telephone:
Business Name:
Eve Telephone:
Street Address:
Fax:
City, State Zip:
Best Time To Reach You:
E-Mail Address:
Current Insurance Information
Insurance Company Name: (NOT Insurance Agency/Broker)
Policy Exp. Date:
Premium Amt:
Term:
How long w/current?
Vehicle Information - (More than 4 Vehicles?
Check here)
(List all cars owned or leased)
Vehicle 1:
Year
Make/Model
Vin #
Yearly Mileage
Usage
Alarm
Vehicle 2:
Year
Make/Model
Vin #
Yearly Mileage
Usage
Alarm
Vehicle 3:
Year
Make/Model
Vin #
Yearly Mileage
Usage
Alarm
Vehicle 4:
Year
Make/Model
Vin #
Yearly Mileage
Usage
Alarm

Any Custom equipment on vehicles?
(if YES, give their value & indicate which vehicle(s):

Debris hauled for others?:
Trailer Hitch?:
Class of Business:
Coverage Information
Liability limits for bodily injury & property damage:
Uninsured Motorist Bodily Injury:
Deductibles
Comp. & Collision
Towing coverage
Rental Reimb.
Vehicle 1:
Vehicle 2:
Vehicle 3:
Vehicle 4:
Driver Information - (More than 4 Drivers?
Check here)
Driver 1
Name:
Sex:
DL # (OPTIONAL):
Marital Status:
Date of birth:
Driver's Education?:
Years Licensed:
Defensive Driving:
Occupation:
Good Student:
Driver 1 SS#:
SR 22 filing?:
Driver 2
Name:
Sex:
DL # (OPTIONAL):
Marital Status:
Date of birth:
Driver's Education?:
Years Licensed:
Defensive Driving:
Occupation:
Good Student:
Driver 2 SS#:
SR 22 filing?:
Driver 3
Name:
Sex:
DL # (OPTIONAL):
Marital Status:
Date of birth:
Driver's Education?:
Years Licensed:
Defensive Driving:
Occupation:
Good Student:
Driver 3 SS#:
SR 22 filing?:
Driver 4
Name:
Sex:
DL # (OPTIONAL):
Marital Status:
Date of birth:
Driver's Education?:
Years Licensed:
Defensive Driving:
Occupation:
Good Student:
Driver 4 SS#:
SR 22 filing?:
Accidents / Violations in the last 5 years?
Driver 1 Driver 2 Driver 3 Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Chargeable Accident Cost($):
Major violations - drunk driving, reckless, hit and run, etc.
Any additional comments or information
that might be helpful in your quote


No coverage of any kind is bound or implied by submitting information via this online form

  • Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

Enter the security code you see above. Code is NOT case sensitive.*

    Desert Country Insurance Group
    "Serving the Entire State of Arizona for over 28 Years"

    Telephone:  (602) 354-7313
    Toll Free:  (877) 926-2542
    Fax:  (602) 978-4526 

    E-mail bestladyagent@cox.net

    Arizona Lic# 268587

    Hours of Operation:
    Monday-Friday
    8:00 am- 7:00 pm
    Privacy Policy | Copyright Information | Notices

     Desert Country Insurance Agency, 2009 Powered By: Insurance Web Designs   webmail login