AGW Auto Rate Check – Insureberry Insurance Agency

1Start Policy

2Driver Information

3Vehicle Information

Let's get you covered

Name (Primary Driver) *

First

Last

Personal Email *

Phone *

Primary Residence

Address *

Address Line 1

City

State

Zip Code

Additional Information

Would you like to add other insurance coverage? (Select all that apply) *

Homeowners
Renters
Farm & Ranch
Commercial Coverage
Motorcycle/ATV
Motorhome
Special Event Insurance
Pet
Umbrella
Other
No, thanks!

All quotes are provided through our wholly-owned subsidiary, Insureberry.

Other, please explain: *

Are you a member of an electric co-op? *

How did you hear about us? *

Please enter your policy # if you have it available:

Leave this area blank if you don't have your policy number on-hand and we will verify this information later.

Please specify which College: *

Convention or Tradeshow Name: *

I was referred by: *

We love referrals, and we'd like to thank your friend/family member for sending you our way. Please include their name and phone # or email. Thank you!

Other, please specify: *

Primary Driver

Primary Driver's DOB *

Gender *

Female
Male

Marital Status *

Single
Married

Occupation *

Driver's License Status *

Regardless of fault, has this driver had any accidents or claims in the last 3 years? *

How many accidents or claims? *

Regardless of fault, has this driver had any tickets or moving violations in the last 3 years? *

How many tickets or moving violations? *

Please check all that apply to the Primary Driver

You've NEVER had an auto policy cancel/non-renew OR had a lapse in coverage (regardless of reason)
You've TAKEN a defensive driving course within the last 3 years
You own/finance a home

Please note that 3rd party reports will be used to verify driving, accident, and credit history.

Credit Score *

Excellent (720-850)
Good (690-719)
Fair (630-689)
Poor (300-629)
I don't know

How will your credit be used? Studies have shown a correlation between a consumer’s financial history and his/her future insurance loss potential. Therefore, when you apply for auto insurance through AgWorkers, we will ask for your permission to check your credit score under FCRA regulations. Your insurance score will be pulled from one of the credit bureaus that calculate your risk based upon financial history along with other factors to properly classify you according to your potential risk. Please note that age, income, gender, race, religion, marital status, and geographical data are not included in this score.

Additional Drivers:

Do you want to add more drivers to your policy? *

How many drivers? *

If you are done adding drivers to your policy, click 'Next' to add vehicles.

2nd Driver's Info

2nd Driver's Name *

First

Last

2nd Driver's DOB *

2nd Driver's Relationship to Primary Driver *

Spouse
Significant Other
Parent
Child
Other

Other, please explain *

Driver's License Status *

Regardless of fault, has this driver had any accidents or claims in the last 3 years? *

How many accidents or claims? *

Regardless of fault, has this driver had any tickets or moving violations in the last 3 years? *

How many tickets or moving violations? *

Click 'Next' to add vehicles.

3rd Driver's Info

3rd Driver's Name *

First

Last

3rd Driver's DOB *

3rd Diver's Relationship to Primary Driver *

Spouse
Significant Other
Parent
Child
Other

Other, please explain *

Driver's License Status *

Regardless of fault, has this driver had any accidents or claims in the last 3 years? *

How many accidents or claims? *

Regardless of fault, has this driver had any tickets or moving violations in the last 3 years? *

How many tickets or moving violations? *

Click 'Next' to add vehicles.

4th Driver's Info

4th Driver's Name *

First

Last

4th Driver's DOB *

4th Diver's Relationship to Primary Driver *

Spouse
Significant Other
Parent
Child
Other

Other, please explain *

Driver's License Status *

Regardless of fault, has this driver had any accidents or claims in the last 3 years? *

How many accidents or claims? *

Regardless of fault, has this driver had any tickets or moving violations in the last 3 years? *

How many tickets or moving violations? *

Click 'Next' to add vehicles.

5th Driver's Info

5th Driver's Name *

First

Last

5th Driver's DOB *

5th Diver's Relationship to Primary Driver *

Spouse
Significant Other
Parent
Child
Other

Other, please explain *

Driver's License Status *

Regardless of fault, has this driver had any accidents or claims in the last 3 years? *

How many accidents or claims? *

Regardless of fault, has this driver had any tickets or moving violations in the last 3 years? *

How many tickets or moving violations? *

Click 'Next' to add vehicles.

A representative will be in touch to add additional drivers. Click 'Next' to add vehicles.

Primary Vehicle Information

VIN of Primary Vehicle

If you don't know this or don't currently have access to the VIN, please enter the Year, Make, and Model below.

Year of Primary Vehicle *

Make/Manufacturer of Primary Vehicle *

Model of Primary Vehicle *

Primary Use: *

Personal (to/from work or school)
Pleasure
Business (sales calls, business errands, etc.)
Farming (agriculture, ranching)
Ride Share (Uber, Lyft, etc.)
Other

Other, please explain: *

Is the vehicle stored/garaged at the primary address you provided earlier? *

Address where primary vehicle is stored/garaged *

Address Line 1

Address Line 2

City

State

Zip Code

Additional Vehicles

Do you want to add more vehicles to your policy?

How many vehicles? *

If you are done adding vehicles to your policy, click 'Submit' to complete your rate check request.

2nd Vehicle's Info

VIN of 2nd Vehicle

If you don't know this or don't currently have access to the VIN, please enter the Year, Make, and Model below.

Year of 2nd Vehicle *

Make/Manufacturer of 2nd Vehicle *

Model of 2nd Vehicle *

Primary Use of 2nd Vehicle *

Personal (to/from work or school)
Pleasure
Business (sales calls, business errands, etc.)
Farming (agriculture, ranching)
Ride Share (Uber, Lyft, etc.)
Other

Other, please explain: *

Is the 2nd vehicle stored/garaged at your primary address? *

Address where 2nd vehicle is stored/garaged *

Address Line 1

Address Line 2

City

State

Zip Code

If you are done adding vehicles to your policy, click 'Submit' to complete your rate check request.

3rd Vehicle's Info

VIN of 3rd Vehicle

If you don't know this or don't currently have access to the VIN, please enter the Year, Make, and Model below.

Year of 3rd Vehicle *

Make/Manufacturer of 3rd Vehicle *

Model of 3rd Vehicle *

What is the 3rd vehicle's primary use? *

Personal (to/from work or school)
Pleasure
Business (sales calls, business errands, etc.)
Farming (agriculture, ranching)
Ride Share (Uber, Lyft, etc.)
Other
Choice 7

Other, please explain: *

Is the 3rd vehicle stored/garaged at your primary address? *

Address where 3rd vehicle is stored/garaged *

Address Line 1

Address Line 2

City

State

Zip Code

If you are done adding vehicles to your policy, click 'Submit' to complete your rate check request.

4th Vehicle's Info

VIN of 4th Vehicle

If you don't know this or don't currently have access to the VIN, please enter the Year, Make, and Model below.

Year of 4th Vehicle *

Make/Manufacturer of 4th Vehicle *

Model of 4th Vehicle *

What is the 4th vehicle's primary use? *

Personal (to/from work or school)
Pleasure
Business (sales calls, business errands, etc.)
Farming (agriculture, ranching)
Ride Share (Uber, Lyft, etc.)
Other

Other, please explain: *

Is the 4th vehicle stored/garaged at your primary address? *

Address where 4th vehicle is stored/garaged *

Address Line 1

Address Line 2

City

State

Zip Code

If you are done adding vehicles to your policy, click 'Submit' to complete your rate check request.

5th Vehicle's Info

VIN of 5th Vehicle

If you don't know this or don't currently have access to the VIN, please enter the Year, Make, and Model below.

Year of 5th Vehicle *

Make/Manufacturer of 5th Vehicle *

Model of 5th Vehicle *

What is the 5th vehicle's primary use? *

Personal (to/from work or school)
Pleasure
Business (sales calls, business errands, etc.)
Farming (agriculture, ranching)
Ride Share (Uber, Lyft, etc.)
Other

Other, please explain: *

Is the 5th vehicle stored/garaged at your primary address? *

Address where 5th vehicle is stored/garaged *

Address Line 1

Address Line 2

City

State

Zip Code

If you are done adding vehicles to your policy, click 'Submit' to complete your rate check request.