AUTO QUOTE | Archer Insurance

Customer Name *

First

Last

Thank you for your interest in Archer Insurance. Who might you be? *

I am the customer
I am a realtor on behalf of a customer
I am a Non-Realtor® professional

How did you hear about Archer Insurance? *

What Real Estate Office? *

Which state is the Keller Williams office in? *

Which New Hampshire Keller Williams office?

Which Connecticut Keller Williams office?

Which Maine Keller Williams office?

Which Vermont Keller Williams office?

Which Massachusetts Keller Williams office? *

Which Rhode Island KW Office?

Keller Williams Agent's Name? *

What is their name, and what office do they work out of? *

Type the name of the KW office you are out of. *

What real estate office are you with? *

Describe your relationship to the customer. *

Are you a loan officer, attorney, accountant, car dealership, or from some other industry?

Your Name *

First

Last

Your Phone # *

Customer Phone *

Your Email *

Customer Email *

Customer Address *

Address Line 1

Address Line 2

City

State

Zip Code

Currently Insured? *

Yes
No

Want to zip right to the end?

Yes
No

By uploading your current insurance declarations page(s) you can bypass the online portal.

Do you have a copy of your declarations page to upload? *

Yes - And I'll use that for an express quote.
No - I'll just continue with this easy online form.

If you have more than one attachment to upload, you can email them all to lou@insurewitharcher.com. Just reference your online quote request in the email. Thanks!

Upload your declarations for express quote

Your declarations are those first few pages of the policy you receive each year from your current carrier. They often come in the mail, but are also easy to pull from your carrier's website. If you don't have access to these, it is as simple as calling your agent and asking them to email you a copy.

Tell us about any changes you'd like us to make to the policy you've uploaded. (For instance; drivers, garaging address, coverage, vehicles, etc.)

How many drivers? *

1
2
3
4

Driver #1 *

First

Last

Driver #1 license number *

Driver #2 *

First

Last

Driver #2 license number *

Driver #3 *

First

Last

Driver #3 license number *

Driver #4 *

First

Last

Driver #4 license number *

Number of vehicles on policy *

1
2
3
4

Does vehicle #1 have MA plates? *

Yes
No

Vehicle #1 plate number

Do you know the VIN# for vehicle #1?

Yes
No

Enter vehicle #1 VIN

Does vehicle #2 have MA plates? *

Yes
No

Vehicle #2 plate number

Do you know the VIN# for vehicle #2?

Yes
No

Enter vehicle #2 VIN

Does vehicle #3 have MA plates? *

Yes
No

Vehicle #3 plate number

Do you know the VIN# for vehicle #3?

Yes
No

Enter vehicle #3 VIN

Does vehicle #4 have MA plates? *

Yes
No

Vehicle #4 plate number

Do you know the VIN# for vehicle #4?

Yes
No

Enter vehicle #4 VIN

Vehicle #1 Year

Vehicle #2 Year

Vehicle #3 Year

Vehicle #4 Year

Vehicle #1 Make

Vehicle #2 Make

Vehicle #3 Make

Vehicle #4 Make

Vehicle #1 Model

Vehicle #2 Model

Vehicle #3 Model

Vehicle #4 Model

Please explain vehicle(s) uses in any form or business?

Any student drivers with a 3.0+ GPA?

Yes
No

Any student drivers live at school?

Yes
No

Place of Employment

We offer discounts to certain employers

Are you an AAA member?

Yes
No

Enter membership #

Current living situation *

Own
Rent
Live with family
Other

If other, please explain

Checking this box indicates that you have read this. *

Archer Insurance is an independent insurance broker licensed by the Commonwealth of Massachusetts. Archer Insurance, Keller Williams Realty Beverly, Keller Williams Realty Eastern Middlesex and Keller Williams Realty Greater Newburyport are independent entities. Each are party to agreements pursuant to which commissions on insurance customer accounts are shared. These agreements do not increase or in any other way affect premiums should you elect to place your insurance coverage thru Archer Insurance.

Sign here demonstrating that you understand the Archer/KW relationship.