Automotive, Home and Life Insurance Quote

Thank you for your interest in SHS Auto, Home and Life Insurance. Please use the form below to provide the information needed so that we may give you an accurate quote.

Contact Information

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Driver 1 Information

Driver 1 Name *

First

Last

Driver 1 Date of Birth *

Driver 1 Driver's License Number *

Driver 1 Social Security Number *

Driver 2 Information

Driver 2 Name

First

Last

Driver 2 Date of Birth

Driver 2 Driver's License Number

Driver 2 Social Security Number

Driver 3 Information

Driver 3 Name

First

Last

Driver 3 Date of Birth

Driver 3 Driver's License Number

Driver 3 Social Security Number

Driver 4 Information

Driver 4 Name

First

Last

Driver 4 Date of Birth

Driver 4 Driver's License Number

Driver 4 Social Security Number

Vehicle Information

Vehicle 1 Year, Make and Model *

Vehicle 2 Year, Make and Model

Vehicle 3 Year, Make and Model

Vehicle 4 Year, Make and Model

Current Coverage

Liability Limits

Medical Limits

Comprehensive Deductibles

Collision Deductibles

Uninsured/Underinsured Motorist

Uninsured/Underinsured Liability Limits

Towing Reimbursement

Yes
No

Rental Reimbursement

Yes
No

Any Losses Incurred

Please list the Date, Description of loss/claim and the amount paid

Homeowner Insurance

Current Coverage

Dwelling Limit

Personal Property Limit

Liability Limits

Deductible

Structure

Construction Year

Type of Construction

Masonry
Frame

Alarm Systems

Yes
No

Fire Detectors
Central Fire Alarm

Local Burglar
Central Burglar Alarm

Basement

Yes
No

Basement Finished

Yes
No

Scheduled Jewelry Limit

Age of Roof

Any Losses Incurred

Please list the Date, Description of loss/claim and the amount paid

Life Insurance

Name *

First

Last

Date of Birth

Smoker

Yes
No

Amount of coverage requested

Upload your current declaration page(s) here

Click or drag files to this area to upload. You can upload up to 10 files.

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