Ford Employees | Chrysler Employees | Credit Union Members

Please complete the information requested below as accurately as possible, and upon your submission a Sterling Personal Insurance Division representative will contact you within 24 hours to provide your quote.

If you wish to speak to a Sterling representative directly, please call our Personal Insurance Division at (586) 323-5700. For the Lansing office call (517) 323-3737.

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Personal Information

Name:*

Employer/Occupation:

Email:*

Address:*

 

City:*

State:*

Zip Code:*

Phone:*

Date of Birth:

Any tickets or accidents in the past 5 years? - Select - Yes No

Current Auto Insurance

Present Insurer:

Annual Premium:

Bodily injury liability - Select - $20,000/40,000 $50,000/100,000 $100,000/300,000 $250,000/500,000 $500,000/1,000,000

Property damage - Select - $10,000 $50,000 $100,000 $250,000 $500,000

Comprehensive Deductible - Select - No Coverage $50 $100 $200 $250 $500 $1000

Collision Deductible - Select - No Coverage $50 $100 $150 $200 $250 $500 $1000

Collision Form - Select - Broad Regular Limited

Health Insurance Carrier:

About Your Household

Spouse/Significant Other:
Name:

Date of birth:

Occupation:

Any tickets or accidents in the past 5 years? - Select - Yes No

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Dependents/Other Household Members:
Name:

Date of birth:

Occupation:

Any tickets or accidents in the past 5 years? - Select - Yes No

Has own insurance? - Select - Yes No

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Dependents/Other Household Members:
Name:

Date of birth:

Occupation:

Any tickets or accidents in the past 5 years? - Select - Yes No

Has own insurance? - Select - Yes No

Vehicle Information

Vehicle 1:
Year:*

Make:*

Model:*

VIN#:

Miles one way to work:*

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Vehicle 2:
Year:

Make:

Model:

VIN#:

Miles one way to work:

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Vehicle 3:
Year:

Make:

Model:

VIN#:

Miles one way to work:

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Remarks:

 

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