Orlando Insurance

Personalized insurance services for over 30 years...
Serving all of Orlando & Central Florida Communities.

2 Locations

Dr. Phillips-Orlando, FL
Winter Park, FL

Auto Insurance Quote

Prefer to talk to an agent?
Call us anytime at
407-855-1000

Please complete the following survey as completely and accurately as possible.  Once the information is submitted we will expedite your request and contact you via your selection.  This information will be kept confidential and will be used for quote purposes only.  We at Harry Levine Insurance look forward to serving you.
 
Customer Information
First name *
Last name *
Email
Contact number * - -
How may we contact you *
Date of birth / /
(example: 10/15/1962)
Street *  Apt  
Home status
ZIP Code *
City *
State *
   
Insured for the last 6 months?
Insuance Company
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Additional comments you feel necessary for this quote


Add Vehicle Information #1
Year
Make
Body Style
 
Odometer Reading
Is this vehicle owned,financed or leased?
Primary use of vehicle
Type of business use
Approximately what percentage of total miles driven are for business
Estimated Annual Mileage
Is your vehicle garaged
Vin Number

Vehicle Location


Same address as above
House # and Street   Apt 
Zip Code
City
State


Add Vehicle Information #2
Year
Make
Body Style
 
Odometer Reading
Is this vehicle owned,financed or leased?
Primary use of vehicle
Type of business use
Approximately what percentage of total miles driven are for business
Estimated Annual Mileage
Is your vehicle garaged
Vin Number

Vehicle Location


Same address as above
House # and Street   Apt 
Zip Code
City
State


Add Vehicle Information #3
Year
Make
Body Style
 
Odometer Reading
Is this vehicle owned,financed or leased?
Primary use of vehicle
Type of business use
Approximately what percentage of total miles driven are for business
Estimated Annual Mileage
Is your vehicle garaged
Vin Number

Vehicle Location


Same address as above
House # and Street   Apt 
Zip Code
City
State


Add Vehicle Information #4
Year
Make
Body Style
 
Odometer Reading
Is this vehicle owned,financed or leased?
Primary use of vehicle
Type of business use
Approximately what percentage of total miles driven are for business
Estimated Annual Mileage
Is your vehicle garaged
Vin Number

Vehicle Location


Same address as above
House # and Street   Apt 
Zip Code
City
State


Driver Information (Applicant)
Please add all of the drivers
in your household

First name
Last name
Relationship to applicant
Date of birth / /
(example: 10/15/2005)
Marital status
Gender
Social Security number - -
Do you currently have auto insurance?
Age US license first obtained  
Full-time student
Current year of study
Employment status
Enter your current occupation
Retired?
National Guard, Military Reserves, or a Military
Number of Tickets (last 5 years)  
Number of Accidents (last 5 years)  


Driver Information #2
Please add all of the drivers
in your household

First name
Last name
Relationship to applicant
Date of birth / /
(example: 10/15/2005)
Marital status
Gender
Social Security number - -
Do you currently have auto insurance?
Age US license first obtained  
Full-time student
Current year of study
Employment status
Enter your current occupation
Retired?
National Guard, Military Reserves, or a Military
Number of Tickets (last 5 years)  
Number of Accidents (last 5 years)  


Driver Information #3
Please add all of the drivers
in your household

First name
Last name
Relationship to applicant
Date of birth / /
(example: 10/15/2005)
Marital status
Gender
Social Security number - -
Do you currently have auto insurance?
Age US license first obtained  
Full-time student
Current year of study
Employment status
Enter your current occupation
Retired?
National Guard, Military Reserves, or a Military
Number of Tickets (last 5 years)  
Number of Accidents (last 5 years)  


Driver Information #4
Please add all of the drivers
in your household

First name
Last name
Relationship to applicant
Date of birth / /
(example: 10/15/2005)
Marital status
Gender
Social Security number - -
Do you currently have auto insurance?
Age US license first obtained  
Full-time student
Current year of study
Employment status
Enter your current occupation
Retired?
National Guard, Military Reserves, or a Military
Number of Tickets (last 5 years)  
Number of Accidents (last 5 years)  


Liability Coverage

Tort Option
(if applicable)		 Liability
Coverage		 Property
Damage		 Uninsured
Motorists		 Personal Injury
Protection
 Coverage Options 
 Rental Reimbursement 
Y N
Towing & Labor
Y N
         


Prefer to talk to an agent?
Call Harry Levine Insurance anytime at:
407-855-1000

Click on the "Submit" button to send your quote request.
Thank you

Protecting your privacy is very important to us. Policyholders like you have trusted us with their insurance needs for over 30 years, and we take our obligation to safeguard and secure your personal information very seriously. Unless you expressly give us permission to do so, or unless required by law, Harry Levine Insurance & Financial Services does not disclose your unique personal information other than for the sole purpose of insurance quotations at your request.

EMAIL ADDRESSES: Your email address shall only be provided to our agents, brokers and/or companies who receive your data so they may confirm, respond and communicate with you. We will also send you a confirmation email after submitting your information for a quote. WE DO NOT SELL OR DISTRIBUTE YOUR EMAIL ADDRESS.

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