Shimkus,
   Murphy &
 Lemkuil, Inc.

    Personal
   Insurance
     Auto Quote
    Health Quote
    Homeowners Quote
    Life Quote
Insurance Real Estate Quotes Links Company Info

Automobile Quote Entry Form

For an instant online quote, enter your zip code above and click the "go" button.

For quotes by phone, call 860.249.1396 x3 from
8:30-5:00 Monday to Friday or
9:00 to 2:00 on Saturday.

Anytime, you can fill out the following information and
click the 'Submit for Health Quote' button below.

First Name: Last Name:
Street:
City: State:
Zip:
Home Phone:
Daytime Phone:
E-mail Address:
Present auto insurance company:
Date present auto insurance expires:
Do you own a home or rent?: Own
Rent
Number of years you have been at your current address:
Date of Birth: Marital Status:
   Addition Drivers Names/Date or Birth/Marital Status:
   
   
   
   Any other drivers in household who own insurance:
   
   
   
   Any accidents/violations in past 5 years(Yes/No)? Dates/details/amount paid:
   
   Any not-at-fault accidents/comp losses in past 5 years(Yes/No)? Dates/details/amount paid:
   
Number of years licensed in CT:
Number of years licensed anywhere in US:
Employment status:
Number of years with current employer:
   Exact year/make/model of each vehicle? Specific sub-model? Body style? 2WD/4WD?:
   
   Enter additional comments:
   
Click above if page is in English. Quotes will not submit from non-English pages.
If this page is not in English, print out this sheet then return to English site
and enter info in same places on English sheet, then click submit.