Christine Tillett
MetLife Auto & Home
Insurance protection for all your needs with integrity and honesty
33305 1st Way S #B102
Federal Way, WA 98003
253-838-5797 (fax)

Our agency is licensed to quote and write insurance policies only in Washington. To find agents offering these coverages in all other states, please click the logo.


 Automobile Insurance Quote
Completely fill out and submit this form to our agency to receive an accurate quote. You MUST provide at least one method of contact to receive a quote from our agency.

General Information

 Name: (required)  
 E-Mail Address: (required)  
 City: (required)  
 State:(required)   Zip: (required)
 Day Phone:  
 Evening Phone:  

Please list your family's drivers
#  First Name   Gender Birth Date  Married?  Social Security # 

In order to provide a PREFERRED policy quote some of the companies that we represent may require a credit and/or claims history. For Preferred quotes, Social Security numbers are required. You do not have to provide social security numbers at this time but we can't guarantee that we can provide the best price available until after we speak with you and secure this credit and/or claim information. 
Check this box to grant our agency permission to secure your credit and/or claim history, for insurance purposes only, under the Fair Credit Reporting Act. Your name  

We need to know about your cars.
Please provide the year, make, model & name of daily driver
Answer should look like this : 1998, Ford, Taurus, Mary

All of this information is required to receive a quotation

Veh#   Year - Make - Model  How is this car used? 

  Annual Miles



Tell us the current coverages on your cars?

 Comprehensive Deductible  
 Collision Deductible  
 Bodily Injury Liability Limit (000)  
 Property Damage Liability Limit  
 Uninsured Motorist Bodily Injury Liability (000)  
 Uninsured Motorist Property Damage Liability  
 Personal Injury Protection  
 Medical Payments  
 Road Service Coverage  
 Rental Car Reimbursement  
 What month current policy expire?  
 What is the name current insurance company?  

Accidents & Violations

Last 3 Yrs (Minors)
Last 5 Yrs (Majors)
Driver 1 Driver 2 Driver 3 Driver 4
Minor Violations - Speeding, Illegal Turn, Stop Sign, Red Light, etc. (Within the last 3 years)
Accidents - Non Chargeable (Within the last 5 years)
Accidents - Chargeable (Within the last 5 years)
Major Violations - Drunk Driving, Reckless, Hit & Run, Speeding - Greater than 30 MPH over limit (Within the last 5 years)

The following information is optional, but if given we will be able to provide you with a more accurate premium quotation.

 Drivers' Information:  
 Driver #
 License Number
(required in California) 
Years Licenced
(required in California) 





Vehicle Identification Numbers
 Veh #1
  Veh #2
 Veh #3

Please use this area to give us any additional information that you may feel is important for your insurance. ie: Is one of your cars used to deliver pizzas or conduct another type of business? Do your young drivers have a B average or better in school?

Are there any additional cars or drivers?


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Page Created 8-13-2004
Latest Revision