"*" indicates required fields Step 1 of 5 - General Information 20% If you would like to bypass the manual entry of this information, you can utilize the "Compare My Insurance" Link at the top of the page to send all information needed in a few simple clicks.Name First Last Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Current Insurance ProviderWhat Brought You To Eastman Insurance Solutions?Please Select OneGoogle SearchBing SearchInsurance Company ReferralReferred By FriendReferred By BusinessFacebookLinkedIn How Many Drivers?*Please Make Selection1234Driver #1Driver NameDate Of Birth Month Day Year Age Licensed?Marital StatusPlease Make SelectionSingleMarriedGenderPlease Make SelectionMaleFemaleOccupationMinor Violations - Last 3 Years012Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.Major Violations - Last 10 Years012Major violations include DUI, Reckless Driving, Speeding Over 100, etc.Accidents - Last 5 Years0123 or MoreInclude ALL accidents regardless of fault.Driver #2Driver NameDate Of Birth Month Day Year Age Licensed?Marital StatusPlease Make SelectionSingleMarriedGenderPlease Make SelectionMaleFemaleOccupationMinor Violations - Last 3 Years012Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.Major Violations - Last 10 Years012Major violations include DUI, Reckless Driving, Speeding Over 100, etc.Accidents - Last 5 Years0123 or MoreInclude ALL accidents regardless of fault.Driver #3Driver NameDate Of Birth Month Day Year Age Licensed?OccupationMarital StatusPlease Make SelectionSingleMarriedGenderPlease Make SelectionMaleFemaleMinor Violations - Last 3 Years012Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.Major Violations - Last 10 Years012Major violations include DUI, Reckless Driving, Speeding Over 100, etc.Accidents - Last 5 Years0123 or MoreInclude ALL accidents regardless of fault.Driver #4Driver NameDate Of Birth Month Day Year Age Licensed?Marital StatusPlease Make SelectionSingleMarriedGenderPlease Make SelectionMaleFemaleOccupationMinor Violations - Last 3 Years012Minor violations include Speeding, Failure to Stop, Failure to Yield, Seatbelt violations etc.Major Violations - Last 10 Years012Major violations include DUI, Reckless Driving, Speeding Over 100, etc.Accidents - Last 5 Years0123 or MoreInclude ALL accidents regardless of fault.Anyone Else In The Home Not Listed As Driver?No1234 How Many Vehicles?Please Make Selection123456Vehicle #1Year, Make, Model, TrimExample: 2015 Lexus 570 BaseVIN (If Available)This Allows Us To Provide The Most Accurate RatesPrimary Driver NamePlease assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles. Annual Miles DrivenAnnual miles are an important rating factor, please be as accurate as possible. Comprehensive Deductible502505001000Your out of pocket expense for damage to your vehicle other than Collision Collision Deductible502505001000Your out of pocket expense for damage to your vehicle from a Collision Is This Vehicle Financed? No Yes Leased Vehicle #2Year, Make, Model, TrimExample: 2015 Lexus 570 BaseVIN (If Available)This Allows Us To Provide The Most Accurate RatesPrimary Driver NamePlease assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles. Annual Miles DrivenAnnual miles are an important rating factor, please be as accurate as possible. Comprehensive Deductible502505001000Your out of pocket expense for damage to your vehicle other than Collision Collision Deductible502505001000Your out of pocket expense for damage to your vehicle from a Collision Is This Vehicle Financed? No Yes Leased Vehicle #3Year, Make, Model, TrimExample: 2015 Lexus 570 BaseVIN (If Available)This Allows Us To Provide The Most Accurate RatesPrimary Driver NamePlease assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles. Annual Miles DrivenAnnual miles are an important rating factor, please be as accurate as possible. Comprehensive Deductible502505001000Your out of pocket expense for damage to your vehicle other than Collision Collision Deductible502505001000Your out of pocket expense for damage to your vehicle from a Collision Is This Vehicle Financed? No Yes Leased Vehicle #4Year, Make, Model, TrimExample: 2015 Lexus 570 BaseVIN (If Available)This Allows Us To Provide The Most Accurate RatesPrimary Driver NamePlease assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles. Annual Miles DrivenAnnual miles are an important rating factor, please be as accurate as possible. Comprehensive Deductible502505001000Your out of pocket expense for damage to your vehicle other than Collision Collision Deductible502505001000Your out of pocket expense for damage to your vehicle from a Collision Is This Vehicle Financed? No Yes Leased Vehicle #5Year, Make, Model, TrimExample: 2015 Lexus 570 BaseVIN (If Available)This Allows Us To Provide The Most Accurate RatesPrimary Driver NamePlease assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles. Annual Miles DrivenAnnual miles are an important rating factor, please be as accurate as possible. Comprehensive Deductible502505001000Your out of pocket expense for damage to your vehicle other than Collision Collision Deductible502505001000Your out of pocket expense for damage to your vehicle from a Collision Is This Vehicle Financed? No Yes Leased Vehicle #6Year, Make, Model, TrimExample: 2015 Lexus 570 BaseVIN (If Available)This Allows Us To Provide The Most Accurate RatesPrimary Driver NamePlease assign a primary driver from the previous page. NOTE: Any listed driver has coverage on all vehicles. Annual Miles DrivenAnnual miles are an important rating factor, please be as accurate as possible. Comprehensive Deductible502505001000Your out of pocket expense for damage to your vehicle other than Collision Collision Deductible502505001000Your out of pocket expense for damage to your vehicle from a Collision Is This Vehicle Financed? No Yes Leased Liability Limits Requested* Basic - $50,000/$100,000 Average - $100,000/$300,000 Preferred - $250,000/$500,000 Ultra Preferred - $500,000/$500,000 Liability provides coverage for those you injure in an accident, outside of your vehicle. Property DamagePlease Make SelectionBasic - $50,000Average - $100,000Preferred - $250,000Ultra Preferred - $500,000Property damage covers the damage you cause to someone else's property in an accident Medical PaymentsPlease Make SelectionRejectBasic - $1,000Average - $2,500Preferred - $10,000Ultra Preferred - $25,000Med-Pay Covers out of pocket medical expenses for injuries sustained by you or other individuals in your car in an accident that is your fault. Optional Coverages Rental Reimbursement Roadside Assistance OEM Replacement Parts Full Glass Coverage Special Equipment Can we assist you with any other policies? Homeowners Insurance Umbrella Insurance Rental Properties/Landlord Insurance Motorcycle Insurance Classic/Collector/Exotic Car Insurance CCW - Firearm Liability/Self Defense Insurance Business Liability Insurance Business Property Insurance Workers Compensation Insurance Commercial Auto Insurance Bonds EIS is a full service insurance agency, with access to over 100 insurance carriers, we can match your insurance needs with the right carrier to assure you are getting the best value for your insurance premium. Secured Document Upload Drop files here or Select files Max. file size: 98 MB, Max. files: 10. If you have copies of your current insurance coverage, it is extremely helpful if you provide your current insurance docs, this allows us to provide a more comprehensive review. Post Custom Field
