Secured by SSL

Personal Auto Quote Request


If you are interested in receiving a free, no obligation quote, please complete the form below. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

All of our forms use a secure connection using 128-bit SSL encryption.  Rest assured your information is secure.


Personal Information
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Alternate Phone Number
E-Mail Address *
Date of Birth *
/ /
Marital Status *
License Number *
Do you rent or own your home?
Current Insurance Provider
Do you currently have insurance?
If no, when did you last have insurance?
/ /
Does this driver have any major violations or claims in the last five years?
Any other drivers in the household?

Driver Information
Name of Driver
Date of Birth
/ /
License Number
Does this driver have any major violations or claims in the last five years?
Driver Information
Name of Driver
Date of Birth
/ /
License Number
Does this driver have any major violations or claims in the last five years?
Driver Information
Name of Driver
Date of Birth
/ /
License Number
Does this driver have any major violations or claims in the last five years?
Vehicle Information
Vehicle 1 Year Model *
Vehicle 1 Make *
Vehicle 1 Model *
Vehicle 1 VIN
Vehicle 2 Year Model *
Vehicle 2 Make *
Vehicle 2 Model *
Vehicle 2 VIN
Vehicle 3 Year Model *
Vehicle 3 Make
Vehicle 3 Model *
Vehicle 3 VIN
Vehicle 4 Year Model *
Vehicle 4 Make
Vehicle 4 Model *
Vehicle 4 VIN
Coverage Options
Coverage
Comprehensive Deductible
Collision Deductible
Property Damage Liability *
Underinsured Motorist - Bodily Injury Limits
Underinsured Motorist - Property Damage Limits
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

           609 W Lincoln Ave, Goshen, IN 46526    (800) 437-5860      Copyright © 2017 Salem Insurance