Here is your opportunity to get a free, no-obligation auto insurance quote. Just follow the instructions below and when you have completed the form press the submit button. Your request will be handle by one of our staff members as soon as possible.

Instructions: Please complete as much of the form below as possible. We do not require that you complete all the information below, but please complete as much information as you can for the most accurate quote.

If you prefer, you may phone our office for a quote by calling us at (304) 269-3231.

Personal Information
Name
Address
City	State Zip
Email Address
Home Phone	Work Phone
Fax
Contact Me Via:	(please select from list below)
First Choice		Second Choice
Marital Status
List All Children Who Live in Household (Please include ages)

Current Auto Insurance Information
Current Auto Insurance Carrier
Expiration Date
How Long With Current Carrier
Current Homeowner's Insurance Carrier	(optional)

Vehicle Information
	Vehicle 1	Vehicle 2	Vehicle 3
Year
Make
Model
Type
# of Doors
Used For
Distance
Annual Mileage
Desired Liability Coverage
	Vehicle 1	Vehicle 2	Vehicle 3
Bodily Injury
Property Damage
Uninsured Motorist Bodily Injury
Uninsured Motorist Property Damage
Under-Insured Motorist Bodily Injury
Under-Insured Motorist Property Damage
Medical Coverage
Deductible Information
	Vehicle 1	Vehicle 2	Vehicle 3
Comprehensive
Collision
Options	Auto Seat Belts	Auto Seat Belts	Auto Seat Belts
	4 Wheel/ Anti Lock Brake	4 Wheel/ Anti Lock Brake	4 Wheel/ Anti Lock Brake
	Auto Alarm	Auto Alarm	Auto Alarm
	Airbags	Airbags	Airbags

Driver Information
	Driver 1	Driver 2	Driver 3	Driver 4
Name
Relationship
Drivers License #
State Issued
How Long Licensed
Date of Birth
Gender
Marital Status

Moving Violations (list all in past 3 years)
	Driver 1	Driver 2	Driver 3	Driver 4
Speeding
DWI/DUI
Traffic Light
Reckless Driving
Failure to Yield
Stop Sign
Other
If other please describe below (indicate driver number / description )
Suspensions / Revocations
	Driver 1	Driver 2	Driver 3	Driver 4
	Suspension Revoked	Suspension Revoked	Suspension Revoked	Suspension Revoked
Any Accidents in Past 3 Years?
	Driver 1	Driver 2	Driver 3	Driver 4
	Yes No	Yes No	Yes No	Yes No
List All Claims (list all in past 3 years - include date, amount paid, description)

Comments / Remarks

NOTICE OF LICENSURE
Robert Ramsey Insurance Services, Inc. is licensed to
conduct business in the State of West Virginia. The information
on this web site is a solicitation to conduct business
only in the aforementioned state of authority.

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