Jeffrey Acklie's Auto Insurance Quote Request

Jeffrey Acklie Insurance Agency

2210 N 91 Plaza
Omaha NE 68134-6022
402-391-1979 phone
402-397-6798 fax

Auto Insurance Quote Request Page

The minimum requirements to receive your free auto insurance quote is to be a resident of Nebraska and complete all items marked with a *.

The more information you supply, the more accurate the quote. All quotes are subject to verification of driving records and other underwriting factors.

Basic Address Information

Name*

Address*

City* Zip Code*

Please supply either a Daytime or Evening Phone Number
Also the best time to call.*

Home Phone Number:

Work Phone Number:

Best Time To Call Morning Afternoon Evening

E-mail Address:

Do you currently own your own home?
Yes No

Current insurance carrier*
(If you do not have a current insurance carrier type in NONE)

Current Policy Number

How long have you been continuously insured? years

Policy Expiration Date/Premium Due Date

Driver Information

	Driver #1	Driver #2	Driver #3	Driver #4
Name*
License
Sex*	Male Female	Male Female	Male Female	Male Female
Date of Birth*
Social Security Number
Tickets in last 3 years*	Please explain in comments below	Please explain in comments below	Please explain in comments below	Please explain in comments below
Accidents in last 3 years*	Please explain in comments below	Please explain in comments below	Please explain in comments below	Please explain in comments below
Good Student Discount	GPA	GPA	GPA	GPA
Daily Commute*	miles one way	miles one way	miles one way	miles one way

Vehicle Information

	Vehicle #1	Vehicle #2	Vehicle #3	Vehicle #4
Year*
Make*
Specific Model*
Passive Restraints	Driver Side Airbag Dual Airbags	Driver Side Airbag Dual Airbags	Driver Side Airbag Dual Airbags	Driver Side Airbag Dual Airbags
Used for Business?	Yes No	Yes No	Yes No	Yes No
Total Annual Miles
VIN#

Coverages Desired

Limit of Bodily Injury Liability
Limit of Property Damage Liability
Uninsured Motorist
Under Insured Motorist
Comprehensive Deductible
Collision Deductible
Towing Emergency Road Service	Yes No	Yes No	Yes No	Yes No
Loss of Use	Yes No	Yes No	Yes No	Yes No

Additional Information/Comments

If you have any tickets or accidents please explain here

If you feel uncomfortable sending the above information over the net, or have any questions, please call my office at: 402-391-1979 and I will gladly answer your questions.
I look forward to helping you.

Your request for a quote or the form

We welcome any additional information, which would help us develope our site futher please send it to us from here: jeff.acklie@farmersinsuranceagency.com

Return to Jeffrey Acklie Insurance Agency.

Please supply either a Daytime or Evening Phone Number Also the best time to call.*
Home Phone Number:
Work Phone Number:
Best Time To Call	Morning Afternoon Evening
E-mail Address:

Do you currently own your own home? Yes No
Current insurance carrier* (If you do not have a current insurance carrier type in NONE)
Current Policy Number
How long have you been continuously insured?	years
Policy Expiration Date/Premium Due Date