Padgett Insurance Agency
PO Box 1119
Richmond Hill, GA 31324

11258 Ford Ave Suite 2
Richmond Hill, GA 31324

Phone: (912) 756 - 6394
Fax: (912) 756 - 2804
Email Us

Request a quote for Personal Auto Insurance

Car insurance is required by law and protects you against financial loss if you have an accident. There are many different factors, such as age, gender, driving record and vehicle type, that can affect your insurance premium. Padgett Insurance Agency will help you choose the right coverage for your needs.

Fields marked with * are required.
When you have completed filling out the form, click the SUBMIT button. All information provided is confidential and will be used solely for the purpose of providing a quote for you.

Applicant Information

*Applicant's Name:

*Phone:

*Email:

*Address:

* City:

*State:

Zip:

Garage location if different from above:

Currently insured?

Yes

If yes, with what company?

Policy expiration date:

If no, reason:

Coverages/Limits of Liability

Bodily Injury Liability (each person-each accident):
Uninsured/Underinsured Liability Limit (each person-each accident):
Property Damage Limit:
Medical Payments:

Vehicle Description/Use

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Year:

Registered State:

VIN:

Make:

Model:

Airbags:

Primary Driver:

Vehicle Usage:

Miles To Work/School (one way):

Annual Mileage:

Comprehensive Deductible:

Collision Deductible:

Optional coverages:

	towing/labor
	rental

	towing/labor
	rental

	towing/labor
	rental

	towing/labor
	rental

Resident & Driver Information

Driver One

Driver Two

Driver Three

Driver Four

Name:

Birth Date:

Gender:

Marital Status:

Relationship to Applicant:

License #:

License State:

Date Licensed:

Convicted or arrested in last 10 years for DUI?

Yes

Accidents/Convictions (verified w/state motor vehicle dept)

Driver #:

Date of Accident/Conviction:

Bodily injury or death:

Yes

Amount of property damage:

Description of accident or conviction:

Driver #:

Date of Accident/Conviction:

Bodily injury or death:

Yes

Amount of property damage:

Description of accident or conviction:

General Information

Any car modified or special equipment?

Yes

Explain:

Any driver's license been suspended or revoked?

Yes

Explain:

Any coverage declined, cancelled or non-renewed during the last 3 years?

Yes

Explain:

Please review your entries for accuracy before submitting your request.