Request Quotation for Auto Insurance Coverage
FirstChoice Insurance FirstChoice Insurance

338 Pearl Ave.
Oshkosh, WI 54903-0766
(920) 235-3450, (800) 368-7536
FAX: (920) 232-8731

Request Quotation

Auto Insurance Coverage

Progress:
  1. Driver Information
  2. Vehicle Information
  3. Coverage Information
  4. Contact Information

Step 1: Driver Information

We are pleased to provide you with a quotation for auto insurance coverage. All you need to do is fill out this simple 4-step form. One of our agents will personally review your request and contact you with a quotation.

Entries marked with an asterisk (*) are required.

Your name:*
Driver Information
Number of covered drivers:
Driver #1
Name:*
Street address:*
City:*
State:*
Zip Code:*
County:*
Driver's license #:*
Social Security #:*
 (xxx-xx-xxxx)
Date of birth:*
 (mm/dd/yyyy)
Occupation:
Employer:
Years with this employer:
Student?:
 Yes:
Student living away from home:
 Yes:
Eligible for good student discount
 Yes:   GPA:
List tickets, accidents or license suspensions in the last 5 years, with approximate date:
List auto insurance claims in the last 5 years, with approximate dates:
Driver #2 Address same as driver #1:
Name:*
Street address:*
City:*
State:*
Zip Code:*
County:*
Driver's license #:*
Social Security #:*
 (xxx-xx-xxxx)
Date of birth:*
 (mm/dd/yyyy)
Occupation:
Employer:
Years with this employer:
Student?:
 Yes:
Student living away from home:
 Yes:
Eligible for good student discount
 Yes:   GPA:
List tickets, accidents or license suspensions in the last 5 years, with approximate date:
List auto insurance claims in the last 5 years, with approximate date:
Driver #3 Address same as driver #1:
Name:*
Street address:*
City:*
State:*
Zip Code:*
County:*
Driver's license #:*
Social Security #:*
 (xxx-xx-xxxx)
Date of birth:*
 (mm/dd/yyyy)
Occupation:
Employer:
Years with this employer:
Student?:
 Yes:
Student living away from home:
 Yes:
Eligible for good student discount
 Yes:   GPA:
List tickets, accidents or license suspensions in the last 5 years, with approximate date:
List auto insurance claims in the last 5 years, with approximate date:
Driver #4 Address same as driver #1:
Name:*
Street address:*
City:*
State:*
Zip Code:*
County:*
Driver's license #:*
Social Security #:*
 (xxx-xx-xxxx)
Date of birth:*
 (mm/dd/yyyy)
Occupation:
Employer:
Years with this employer:
Student?:
 Yes:
Student living away from home:
 Yes:
Eligible for good student discount
 Yes:   GPA:
List tickets, accidents or license suspensions in the last 5 years, with approximate date:
List auto insurance claims in the last 5 years, with approximate date:

NOTE:

The information you submit will be transmitted from this Web site to our staff via email through the Internet. Additionally, information you enter will be transmitted from your computer to our Web site in un-encrypted form. We believe that this transmission is unlikely to be intercepted, but we cannot guarantee privacy of the information you submit while it is passing through the Internet. If you do not wish to submit this form from the Web, please feel comfortable contacting us by telephone, FAX or other postal mail, and we will be happy to respond to you in that way.