Home Page
return to home page







This is a request for a quote of automobile insurance in the state of South Dakota. There is absolutely no obligation to purchase insurance by filling out this form. Also, no insurance coverage whatsoever can be bound by filling out this form. If coverage is later requested, an application for insurance will need to be signed and a down payment of premium made. Any rates given are subject to the companies final review and approval. Descriptions of coverages given below are only brief general statements about some of the coverages available.


Contact Information

  Name 
  Address 
  City, State ZIP 
  Phone 
  E-Mail 
  FAX 


Residence Information

  Primary Residence 
  Years at Address 


Automobile Insurance History

 Do you currently have automobile   
 insurance?   
yes 
no 
Current Company
  
 Have you maintained continuous    
 insurance for the last year without   
 a lapse in coverage?   
yes 
no 
Expiration
Date
Years with
Current


Driver Information

    Driver #1    Name  
   Birthdate    
      
  Sex    male 
female 
  Marital  
  Status  
single 
married 
    License #        SSN #   
 Check discounts    
 if applicable:    
driver training  
good student  
senior accident 
  prevention course 

    Driver #2    Name  
   Birthdate    
      
  Sex    male 
female 
  Marital  
  Status  
single 
married 
    License #        SSN #   
 Check discounts    
 if applicable:    
driver training  
good student  
senior accident 
  prevention course 

    Driver #3    Name  
   Birthdate    
      
  Sex    male 
female 
  Marital  
  Status  
single 
married 
    License #        SSN #   
 Check discounts    
 if applicable:    
driver training  
good student  
senior accident 
  prevention course 

    Driver #4    Name  
   Birthdate    
      
  Sex    male 
female 
  Marital  
  Status  
single 
married 
    License #        SSN #   
 Check discounts    
 if applicable:    
driver training  
good student  
senior accident 
  prevention course 


Traffic Violations

 List all minor violations (speeding, stop sign, etc.) for the last 3 
 years, and all major violations (DWI, reckless driving, etc.) for 
 last 5 years.  List the DRIVER, DATE, and TYPE OF VIOLATION. 


Accidents

 List all accidents which occurred in the last 3 years. List the 
 DRIVER, DATE, FAULT, AMOUNT, and a BRIEF DESCRIPTION. 


Vehicle Information

Vehicle #1 Information
Year Make Model Vehicle ID # Primary Driver
 Driven to work or school?    Days a Week    Miles One-Way
 Vehicle used for business?    Used on a farm?

Vehicle #2 Information
Year Make Model Vehicle ID # Primary Driver
 Driven to work or school?    Days a Week    Miles One-Way
 Vehicle used for business?    Used on a farm?

Vehicle #3 Information
Year Make Model Vehicle ID # Primary Driver
 Driven to work or school?    Days a Week    Miles One-Way
 Vehicle used for business?    Used on a farm?

Vehicle #4 Information
Year Make Model Vehicle ID # Primary Driver
 Driven to work or school?    Days a Week    Miles One-Way
 Vehicle used for business?    Used on a farm?


Required Coverages and Limits

click here for description

  Liability - Bodily Injury Limits 
  Liability - Property Damage Limit 
  Medical Payments Limit 
  Uninsured Motorists Limits  (same as Bodily Injury limits)
  Underinsured Motorists Limits  (same as Bodily Injury limits)


Physical Damage Coverages

click here for description

  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Comprehensive Deductible
Collision Deductible


Other Optional Coverages

click here for description

  Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Towing
Rental
Special Equipment
$

$

$

$


Death and Disability Coverages

click here for description

 Death Benefits  (required by law unless rejected) 
 Disability Benefits  (required by law unless rejected) 


Comments



When you are finished filling out this form, click on the "quote" button below to send the information.








Copyright 2000 Strait Insurance Agency, Inc. All rights reserved.


















































Liability Coverage - Pays for other people's injuries and damage to their property if you or someone else cause an accident while driving your vehicle. It protects your assets in the event you are held liable for damages to others.

     In this example for Bodiliy Injury limits:     $25,000 / $50,000

                                 $25,000 is the bodily injury limit for each person, and
                                 $50,000 is the bodily injury limit for each accident.

     In this example for the Property Damage limit:     $25,000

                                 $25,000 is the property damage limit for each accident.


Medical Payments Coverage - Pays for medical expenses incurred by you or your passengers while occupying an insured vehicle.

     In this example for the Medical Payments limit:     $2,000

                                 $2,000 is the medical payments limit for each person.


Uninsured and Underinsured Motorists Coverage - Pays bodily injury claims for you or your passengers if you are injured by a negligent uninsured motorist, hit-and-run vehicle, or a negligent driver without adequate insurance.


click here to return to Required Coverages and Limits





Other Than Collision (Comprehensive) Coverage - Pays for damage to your car caused by theft, fire, windstorm, hitting an animal, glass breakage and many other non-collision occurrences.

Collision Coverage - If your car collides with another vehicle or object, this coverage pays to repair your auto.

Deductible - The portion of the loss you must pay yourself before the insurance coverage pays.


click here to return to Physical Damage Coverages





Towing - This optional endorsement provides coverage for towing and labor costs performed at the place of disablement.

Transportation Expenses (Rental) - This coverage can only be added to vehicles with Other than Collision and Collision coverages. There must be damages from an insured loss for this coverage to apply. The limits shown above are: amount per day / maximum amount payable.

Special Equipment - Coverage can be added to an auto policy for either customized vehicles, or to vehicles that have had special items added to them. Customized vehicles may have special paintings, graphics, decals, furniture, carpeting, or facilities for cooking and sleeping. Coverage may also be added to an auto policy for: non-standard stereo equipment, discs or tapes, telephones, CB radios, pickup toppers, and similar items.


click here to return to Other Optional Coverages





Death Benefits - Provides a $10,000 accidental death benefit resulting from bodily injury caused by an accident.

Disability Benefits - Provides limited disability benefits for bodily injury caused by an accident up to a maximum payment period of one year.


click here to return to Death and Disability Coverages




top of the page