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Do you need a detailed online quote? Then choose Auto, Homeowners, Business, Recreational or Life below, and fill out a short form to get a quote from one our specialty agents.
A & C Insurance Agency Inc.        ,
        Jacksonville        ,
        Flordia        A & C Insurance Agency Inc.        ,
        Jacksonville        ,
        Flordia        A & C Insurance Agency Inc.        ,
        Jacksonville        ,
        Flordia        A & C Insurance Agency Inc.        ,
        Jacksonville        ,
        Flordia        A & C Insurance Agency Inc.        ,
        Jacksonville        ,

Auto Quote | A & C Insurance Agency Inc.

Start An Auto Quote Today!

You are only required to complete the first section of this form in order to receive a response from an agent. Any other information you would like to enter on this form is optional.

Personal Information

Name Email Address
Address Day Phone
City Night Phone
State Best Time to Call    AM    PM
Preferred Contact Method   Email    Phone

Current Auto Insurance Information

Company Name Policy
Premium Amount Term
Are You A Homeowner?   Y   N Insurance

Vehicle Information

(include all cars you or your family members own or lease)
Car #1
Year Make Model Body Type Vehicle ID# (VIN)
Name of Title Holder Annual Milage Drive to school/work? # of miles
(one way)
  Airbags   Car Alarm
 Y  N
 Y   N
 Y   N
If vehicle is kept at an address other than that listed above, please indicate below
Location City:   State:   Zip:
Driver Name

Car #2 (enter info)

Car #3 (enter info)

Car #4 (enter info)

Liability Limit

(for all cars)
Choose either   Bodily Injury   and   Property Damage   or   Single Limit
Bodily Injury
Property Damage
Single Limit

Other Coverages

Personal Injury Protection/Medical Payments
Uninsured/Underinsured Motorist - Bodily Injury
Uninsured/Underinsured Motorist - Property Damage

Texas and Arkansas insurers must offer you $2,500 in Personal Injury Protection, but you can buy more. Texas and Arkansas require insurance applicants to reject PIP coverage in writing if they don't want it.

Deductibles and Misc.

Car# Comprehensive Deductible Collision Deductible Towing Rental Reimbursement

Driver Information

(include all licensed drivers in your household)
Driver #1
Driver's Name Drivers License Information
DL#: State: Yr's Licensed:
Relation Date of Birth Sex Marital Status Courses Completed Last 3 yrs
 Married       Single Drivers Ed:  Y  N 
Defensive Driving:  Y  N 
Drug & Alcohol Awareness:  Y  N 
Driver's SSN

Driver #2 (enter info)

Driver #3 (enter info)

Driver #4 (enter info)

Driver History

List ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Driver Date Type of Conviction Speed Over Limit

List ANY driver who has had license suspensions, revocations or DUI convictions below
Driver License Suspended or Revoked DUI Conviction For:
 Suspended    Revoked    Alcohol    Drugs  
 Suspended    Revoked    Alcohol    Drugs  

List ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver Date Description Cost Injuries At Fault
$  Yes  Yes
$  Yes  Yes
$  Yes  Yes
$  Yes  Yes

Additional Comments

Submission of quote request form to this agency does not constitute a binding confirmation of new or revised insurance coverage.