CREDIT UNION MEMBERS
PRINTABLE QUOTE REQUEST SHEET
Mail to: Shimko Insurance, 880 Route 522, Selinsgrove, PA 17870
Or Fax to: 570-374-3411
Or Phone the information into our Office at: 800-730-3462
Please complete for a Free, No Obligation Insurance Quote
Auto Information
Year ____________ Make ____________________ Model_____________ 2dr 4dr sw 4X4
VIN _______________________________________________
Customer Information
Name:_______________________________________ Date of Birth ______________________
Homeowner Yes or No **SSN _______-______-______________
Address:__________________________________________________________ Married: Yes or No
City:________________________________State:_____________ Zip:____________________
Home Phone:_________________________________
Garaged at above address: Yes or No
Number of Operators __________ Additional Operators Name: ________________
Additional Operators DOB __________ Relationship to Insured: ________________
(Please disclose for all Drivers)
Comprehensive Claims Last 3 Years? ____________
Minor Violations Last 3 Years? ______________
Major Violations Last 3 Years? ______________
At Fault Accidents Last 3 Years? ______________
Not At Fault Accidents Last 3 Years? ____________
Valid Drivers License? YES or NO Member of AAA? YES or NO
** I understand that the above information may be verified from credit reports, claims history and driver records.
Signature: __________________________________________________
(___) I would like a Home Insurance Quote
(___) I would like a Life Insurance Quote
(___) I would like a Renters Insurance Quote
(___) I have additional questions, please contact as soon as possible.