1.Please enter your contact information below:(Required.)

Full Name:

House # and Street:

City & State:  

Zip Code:  

Preferred Phone Number:  

Preferred Email:  

2.If you are an educator, at which school are you currently employed?

3.Please list all drivers in the household and their date of birth:(Required.)

Driver #1:

Date of Birth:  

Driver #2:

Date of Birth:  

Driver #3:

Date of Birth:  

Driver #4:

Date of Birth:  

Driver #5:

Date of Birth:

4.Please list all vehicles in the household:
(list the year, make and model for each vehicle)(Required.)

Vehicle #1:

Veh #1 Year Purchased:

Vehicle #2:

Veh #2 Year Purchased:

Vehicle #3:

Vehicle #3 Year Purchased:

Vehicle #4:

Veh #4 Year Purchased:

Vehicle #5:

Veh #5 Year Purchased:

Vehicle #6:

Veh #6 Year Purchased:

5.Please select any additional discounts that may apply:

NEA Member Discount (OEA, WEA, BEEA, etc)

Good Student Discount (3.0 or higher GPA for drivers age 16-25)

Defensive Driving Discount (55 and older and have completed a defensive driving course)

Payroll Discount (must be with participating district)

Accident Free (no accidents for any drivers in the last 3 years)

Violation Free (no tickets for any drivers in the last 3 years)

6.Tickets/Violations for all drivers:
(in the last 3 years)

Driver Name, Date of Conviction, and Violation Type:   

Driver Name, Date of Conviction, and Violation Type:

Driver Name, Date of Conviction, and Violation Type:

Driver Name, Date of Conviction, and Violation Type:

7.Please provide current insurance information:

Carrier Name:   

How much do you pay monthly for auto insurance?   

8.Would you be interested in any of the following?
(FYI: The more you bundle, the more you save!)

Life Insurance

Retirement Planning

Accident Insurance

Homeowners Insurance

Renters Insurance

Motorcycle/Boat/ATV Insurance

Student Loan Solutions

9.By clicking below you agree to allowing us to obtain your insurance score which uses an algorithm to determine risk (Click here for disclosures) 
If you need to add additional drivers, vehicles, recreational vehicle information, or if you have any comments or questions, please list them here:

10.How did you hear about us?

Horace Mann representative came to my schoolEmailFlyer at schoolMailerReferred by: