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801-999-8346

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Secure Auto Quote

Step 1 of 3 - Personal Info

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Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email
Gender*
- Male
- Female
Marital Status*
- Single
- Married
- Divorced
- Widow / Widower

Additional Drivers*
If yes please include their info in the next field.
- Yes
- No
Additional Driver Info
Please include the names and birth dates of each additional driver.
Do you or any other drivers have any accidents or tickets within the past 3 years?*
If yes please include them in the next field.
- Yes
- No
Accident and ticket info
Enter any info for accidents and/or tickets for all drivers.
Drivers Licence Number of each driver
Social Security Number
This is only used to check your DMV report and insurance score. This does not affect your credit in any way.
Do you or anyone in your household consume alcohol?*
- Yes
- No

How Many Vehicles Will Be On The Policy?*
- One
- Two
- Three
- Four or More
V.I.N. or Year, Make, Model of each vehicle.*
The V.I.N. is usually located on the drivers side of the dashboard next to the windshield (V.I.N. stands for Vehicle Identification Number).
Who are the vehicle/vehicles registered to?*
- All vehicles are registered to someone on this policy
- At least one vehicle is registered to someone else
Have you had continuous prior insurance for the past 6 months?*
- Yes
- No
Do you want full coverage or liability only?*
Full coverage is required if there is a loan on the vehicle.
- Full Coverage
- Liability Only
- Multiple vehicles will have different coverages
Different Coverages
If the policy will require both liability and full coverage for different vehicles, please describe each vehicle here.
Liability Limits*
If you will have full coverage on any vehicle please let us know what liability limits you will need.
- 25/65 (State Minimum)
- 50/100
- 100/300
- 250/500
- Other Amount
Deductible (For full coverage vehicles only)*
- $250
- $500
- $1000
- Liability Only - No Deductible
- Other Deductible Amount

My Insurance Utah
5005 South 900 East Suite 100
Salt Lake City, Utah 84117
801-999-8346

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