Auto Insurance Quote
Get an instant online quote from LA West Insurance Inc or complete the short form below and we will get back to you right away with your free quote.
Auto Insurance Quote
Full Name:
Street Address:
City, State & Zip:
E-Mail Address:
# of years @ Current Address:
Do You Own a Home?:
Select
Yes
No
Daytime Phone Number:
Evening Phone Number:
Fax Number:
Best Time To Reach You:
Select
Mornings
Afternoons
Evenings
Weekends
Anytime
Current Insurance Information
Insurance Company Name:
NOT Insurance Agency/Broker
Policy Exp. Date:
(mm/dd/yy)
Term:
Premium Amt:
How long with current?:
Vehicle Information
(List all cars owned or leased)
Vehicle 1:
Year:
Make/Model:
Vin #:
Yearly Mileage:
Usage:
Alarm:
Select
Pleasure
Work over 3 mi
Work less 3 mi
Business
Select
Yes
No
Vehicle 2:
Year:
Make/Model:
Vin #:
Yearly Mileage:
Usage:
Alarm:
Select
Pleasure
Work over 3 mi
Work less 3 mi
Business
Select
Yes
No
Vehicle 3:
Year:
Make/Model:
Vin #:
Yearly Mileage:
Usage:
Alarm:
Select
Pleasure
Work over 3 mi
Work less 3 mi
Business
Select
Yes
No
Vehicle 4:
Year:
Make/Model:
Vin #:
Yearly Mileage:
Usage:
Alarm:
Select
Pleasure
Work over 3 mi
Work less 3 mi
Business
Select
Yes
No
Any Custom equipment on vehicles?
(if YES, give their value & indicate which vehicle):
Coverage Information
Liability limits for bodily injury & property damage:
Select
Yes
No
Uninsured Motorist Bodily Injury:
Select
Yes
No
Deductibles
Vehicle 1:
Comp. & Collision:
Towing coverage:
Rental Reimb #:
Select
Yes
No
Select
Yes
No
Select
Yes
No
Vehicle 2:
Comp. & Collision:
Towing coverage:
Rental Reimb #:
Select
Yes
No
Select
Yes
No
Select
Yes
No
Vehicle 3:
Comp. & Collision:
Towing coverage:
Rental Reimb #:
Select
Yes
No
Select
Yes
No
Select
Yes
No
Vehicle 4:
Comp. & Collision:
Towing coverage:
Rental Reimb #:
Select
Yes
No
Select
Yes
No
Select
Yes
No
Driver Information
Driver 1:
Name:
DL #:
Date of birth:
Years Licensed:
Occupation:
Driver 1 SS#:
Sex:
Martial Status:
Driver's Education?:
Select
Male
Female
Select
Married
Single
Select
Yes
No
Defensive Driving:
Good Student :
SR 22 filing?:
Select
Yes
No
Select
Yes
No
Select
Yes
No
Driver 2:
Name:
DL #:
Date of birth:
Years Licensed:
Occupation:
Driver 1 SS#:
Sex:
Martial Status:
Driver's Education?:
Select
Male
Female
Select
Married
Single
Select
Yes
No
Defensive Driving:
Good Student :
SR 22 filing?:
Select
Yes
No
Select
Yes
No
Select
Yes
No
Driver 3:
Name:
DL #:
Date of birth:
Years Licensed:
Occupation:
Driver 1 SS#:
Sex:
Martial Status:
Driver's Education?:
Select
Male
Female
Select
Married
Single
Select
Yes
No
Defensive Driving:
Good Student :
SR 22 filing?:
Select
Yes
No
Select
Yes
No
Select
Yes
No
Driver 4:
Name:
DL #:
Date of birth:
Years Licensed:
Occupation:
Driver 1 SS#:
Sex:
Martial Status:
Driver's Education?:
Select
Male
Female
Select
Married
Single
Select
Yes
No
Defensive Driving:
Good Student :
SR 22 filing?:
Select
Yes
No
Select
Yes
No
Select
Yes
No
Accidents / Violations in the last 5 years?
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Chargeable Accident Cost($):
Major violations - drunk driving, reckless, hit and run, etc.
Driver 1
Driver 2
Driver 3
Driver 4
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Select
Yes
No
Any additional comments or information that might be helpful in your quote:
No coverage of any kind is bound or implied by submitting information via this online form
Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.
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Hours of operation
M-F:
8:30am-8:00pm
Sat:
9:00am-5:00pm
Sun:
Closed
Contact LA West Insurance Inc today for getting insured in 15 minutes.
Membership Advantages
As a Preferred Club member,Our Company provides you with a variety of 24-hour services and discounts.
Learn More...
Los Angeles Insurance Service Discounts
Roadside Assistance
Automotive Discounts
Amusment Park Discounts
Pharmacy and Prescription Discounts
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