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RGC INSURANCE AGENCIES
Roscommon
| (989)275-5555 | 400 N 5th St. Roscommon 48653
Grayling
| (989)348-4444 | 2411 I75 Business Loop Grayling 49738
Coopersville
| (616)850-1111 | 297 Main St Coopersville MI 49404
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Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Contact Info
Please make sure to be entirely accurate; any inaccurate information could cause a multitude of issues and potentially a loss of coverage.
Driver Info
Number of Drivers in Household
*
1 Driver
2
3
4
5
6
7
8
9
10+
No matter if the drivers are insured elsewhere, we need to know all drivers that are in the household.
Driver 1
*
First
Last
Driver 1: Date of Birth
*
Driver 1: License #
*
Employer?
*
Miles to Work?
*
Driver 2
*
First
Last
Driver 2: Date of Birth
*
Driver 2: License #
*
Employer?
*
Miles to Work?
*
Driver 3
*
First
Last
Driver 3: Date of Birth
*
Driver 3: License #
*
Employer?
*
Miles to Work?
*
Driver 4
*
First
Last
Driver 4: Date of Birth
*
Driver 3: License #
*
Employer?
*
Miles to Work?
*
Vehicle/Coverage Info
Liability Limits
*
$1,000,000/$1,000,000
$500,000/$1,000,000
$500,000/$500,000
$250,000/$500,000
UMBRELLA/EXCESS Needed
Are all vehicles owned in your/spouse's name?
*
No
Yes
Vehicles on the Road (needing liability)
*
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicles with a Loan/Lease
*
None
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Who is loan through? Please indicate which vehicle, or N/A if not applicable
*
Veh 1: Year/Make/Model
*
Vehicle 1: VIN
*
Veh. 1: Comprehensive
*
None
$0 Deductible
$100 Deductible/Full glass
$100 Deductible
$250 Deductible/Full Glass
$250 Ded
$500 Ded/Full Glass
$500 Ded
$750 Ded/Full Glass
$750 Ded
$1000 Ded/Full Glass
$1000
Veh 1: Collision
*
None
$250 Deductible/Regular Form
$250 Deductible/Broad Form
$500 Regular Form
$500 Broad Form
$750 Regular Form
$750 Broad Form
$1000 Regular Form
$1000 Broad Form
Veh 1: USE
*
CHOOSE FROM DROPDOWN
GOVERNMENT USE
Pleasure Use (personal errands only)
Commute 1-10 miles
Commute 11-20 miles
Commute 20+ miles
Business Use
Veh 2: Year/Make/Model
*
Vehicle 2: VIN
*
Veh 2: Comprehensive
*
None
$0 Deductible
$100 Ded/Full Glass
$100
$250/Full Glass
$250
$500/Full Glass
$500
$750/Full Glass
$750
$1000/Full Glass
$1000
Veh 2: Collision
*
None
$250/Regular Form
$250/Broad Form
$500/Regular Form
$500/Broad Form
$750/Regular Form
$750/Broad Form
$1000/Regular Form
$1000/Broad Form
Veh 2: USE
*
CHOOSE FROM DROPDOWN
GOVERNMENT USE
Pleasure Use (errands only)
Commute 1-10 miles
Commute 11-20 miles
Commute 20+ miles
Business Use
Veh 3: Year/Make/Model
*
Vehicle 3: VIN
*
Veh 3: Comp
*
None
$0 Deductible
$100/Full Glass
$100
$250/Full Glass
$250
$500/Full Glass
$500
$750/Full Glass
$750
$1000/Full Glass
$1000
Veh 3: Collision
*
None
$250 deductible/Regular Form
$250/Broad Form
$500/Regular Form
$500/Broad Form
$750/Regular Form
$750/Broad Form
$1000/Regular Form
$1000/Broad Form
Veh 3: USE
*
CHOOSE FROM DROPDOWN
GOVERNMENT USE
Pleasure Use (errands only)
Commute 1-10 miles
Commute 11-20 miles
Commute 20+ miles
Business Use
Veh 4: Year/Make/Model
*
Vehicle 4: VIN
*
Veh 4: Comp
*
None
$0
$100/Full Glass
$100
$250/Full Glass
$250
$500/Full Glass
$500
$750/Full Glass
$750
$1000/Full Glass
$1000
Veh 4: Collision
*
None
$250/Regular Form
$250/Broad Form
$500/Regular Form
$500/Broad Form
$750/Regular Form
$750/Broad Form
$1000/Regular Form
$1000/Broad Form
Veh 4: USE
*
CHOOSE FROM DROPDOWN
GOVERNMENT USE
Pleasure Use (errands only)
Commute 1-10 miles
Commute 11-20 miles
Commute 20+ miles
Business Use
Towing/Roadside Assistance?
*
NONE
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Rental Reimbursement?
*
NONE
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicles Needing Loan/Lease Gap
*
NONE
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Discounts
Are you currently insured?
*
Yes
No
Current company you are insured with (not agency)
*
Group Member?
*
Alumni
Credit Union
Chamber of Commerce Member
Other
None
Date your policy expires?
*
Medical Insurance that covers auto-related injuries as primary?
*
Unsure
Yes
None
Willing to pay premium in full?
*
NO
YES
Company insuring your home/renters/condo?
*
Please list any tickets, accidents or losses with their approximate date and details from last 3 years (if none, indicate so):
*
Submit