Imperial Agency of Pennsylvania - fast free PA Insuance Quotes Pennsylvania Insurance quotes

click here for instant insurance quotes!
Low Cost Auto insurance for PA residents and businesses from the Imperial Agency


How Can We Help Today?

Instant Home or Auto Insurance Quote click for business and commercial insurance quote
click for contractor's liability insurance quote
click for garagekeepers  insurance quote
click for cargo, bobtail and truck insurance quote

click for motorcycle insurance quote
click for homeowners quote
click for renters quote
click for personal umbrella insurance quote
click for more about our notary services
Free Online INSTANT Auto Quote from Progressive:

Learn More About Our Agency
Office Map/Directions
Policy Service/Certificates
Our Notary Notice
Our Privacy Notice
Our Mobile Site


 
 
On-Line Automobile
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: (Must be Pennsylvania)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Primary Insured's Occupation:
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)


DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No If YES to SR22 filing, why needed?
(list accident/cite)
Give details on all violations or accidents:


DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No Comments or
Remarks?
Give details on all violations or accidents:
ADDITIONAL DRIVERS:
If More than 2 Drivers, list Additional Drivers' Names, Birthdates, and driving record history here:


VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
 
Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?
YES NO
 
Uninsured Motorists
Coverage?
YES NO
 
Medical and/or
PIP Coverage?
YES NO
 
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits - - - Liability Limits Must
Match Vehicle #1 - - -
 
Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?
YES NO
 
Uninsured Motorists
Coverage?
YES NO
 
Medical and/or
PIP Coverage?
YES NO
 
Comments or Remarks:
(List additional drivers, autos, etc. here)
ADDITIONAL VEHICLES: If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:


Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me an Auto Quote NOW!


Help Us Fight SPAM! Please enter the code#
below in the box, to show you are human!

CAPTCHA Image
Reload Image

Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!


We Represent These Fine Insurance Companies & More!
the many carriers Imperial Agency.com represents
The Imperial Agency Main Office: 193 W. City Avenue  |  Bala-Cynwyd, PA 19004  |  Phone: 610-617-8850  |  Fax: 610-617-8635
Philadelphia Mayfair Shopping Center Office: 6420 Frankford Ave., #U21  |  Philadelphia, PA 19149  |  Phone: 215-624-5220  |  Fax: 215-624-1197
Policy Service  |  Privacy Notice  | About Our Agency


Visit Our Specialty Insurance Web Sites & Start Saving!

Philadelphia Motorcycle Insurance
Pennsylvania Contractors Insurance
Philadelphia Homeowners Insurance
Pennsylvania Homeowners Insurance
Pennsylvania Renters Insurance
Pennsylvania Truck Insurance
Imperial Auto & Truck Tags


Web Site Design © 2014 Insurance-Web-Sales