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(304) 342-7183 • 239 Capitol Street • Charleston, WV 25301
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Home > Automobile > Car Insurance Quote
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Car Insurance Quote


In order than an accurate quote may be prepared, it is requested that all fields are required to be filled in.

Personal Information
First Name *
Last Name *
Date of Birth *
/ /
Social Security Number
License Number *
License State *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Occupation *
Marital Status (if Married, Spouse Info is Required for Quoting)) *
Other Driver(s) in Household? (If Yes, enter required info in the comment box below) *

Other Driver(s) Info: (Name, including M.I., Birth Date, Driver's License, Issue State, if not WV, Occupation and Relationship to you) *
Accidents/Violations
Violations? For each, please include: Date, Driver, Nature of Incident *
Claims/Property Losses in Past 5 Years (Please Explain)
Describe the Loss *
Do you currently have insurance?
Current Insurance Provider
Current Coverage
Cost of Previous Coverage Per Month
Current Policy End Date
/ /
Liability Limit
Vehicle One
Vehicle 1 Year Model *
Vehicle 1 Make *
Vehicle 1 Model *
Vehicle 1 VIN
Vehicle 1 - Comprehensive Deductible
Vehicle 1 - Collision Deductible
Vehicle 1 - Average Commute in Miles
Vehicle 1 - How many days per week do you commute?
Vehicle 1 - Towing
Vehicle 1- Rental
Vehicle Two
Vehicle 2 Year Model *
Vehicle 2 Make *
Vehicle 2 Model *
Vehicle 2 VIN
Vehicle 2 - Comprehensive Deductible
Vehicle 2 - Collision Deductible
Vehicle 2 - Average Commute in Miles
Vehicle 2 - How many days per week do you commute?
Vehicle 2 - Towing
Vehicle 2- Rental
Vehicle Three
Vehicle 3 Year Model *
Vehicle 3 Make
Vehicle 3 Model *
Vehicle 3 VIN
Vehicle 3 - Comprehensive Deductible
Vehicle 3 - Collision Deductible
Vehicle 3 - Average Commute in Miles
Vehicle 3 - How many days per week do you commute?
Vehicle 3 - Towing
Vehicle 3- Rental
Lein Holder Information
Lien Holder
Lien Holder Phone Number
Lien Holder address *
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.

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Location 239 Capitol Street Charleston, WV 25301
Contact Ph: (304) 342-7183 | Fx: (304) 346-1395 | Email: cbhall@wvdsl.net
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