Request Quote – Glaze Agency

Insurance Quote Request

You have two options for receiving your quote

By Email. We understand people are busy and many times are shopping online from work in their spare time, but do not have the free time to talk on the phone. If this pertains to you, please be sure to fill out ALL fields of the request form. This is the minimal amount of information we will need to email you an accurate quote. Please feel free to respond with any questions or changes you would like to see made to that quote.

By Phone. We would be happy to take 10-15 minutes to tailor a quote to your exact needs. Just leave us a best time to call you in the comments section. Please feel free to ask us any questions about your quote. We are here to make sure you understand all your options and are comfortable with your policy before purchasing.

First Name

Primary Insured

Last Name

Primary Insured

Street Address

123 Main St

City

Zip Code

Are you a current customer?

Mobile Number

Email Address

What are you interested in? (Check all that apply)

Home Auto Life Motorcycle Boat/Specailty Business Renter’s (or Landlord) Umbrella

Driver’s License Number of Primary

*Only required if you would like us to email you a quote without speaking over the phone.* We use this number to see insurance history required for a quote.

Date of Birth of Primary

MM-DD-YYYY

Additional Driver(s)

Please include full name, birth date, and relationship to primary.

Additional Driver(s)

Please include full name, birth date, and relationship to primary.

Please include any additional information or Promo Codes you may need to provide.

Please include items like: Best time to call you. Year/Make/Model for all vehicles. Any ticket/accident information for the last 3 years. Desired policy limits and deductibles you would like to see quoted. Any questions you may have.

I agree to terms and conditions.

By clicking “Submit” below you agree that you have read and agree to our Privacy Statement located at the bottom of the page. You are also consenting Farmers to use the consumer report information we currently have on file for you for this specific transaction. You will still be able to opt out of any future sharing. The credit inquiry used for this is known as a Soft Inquiry. Soft inquiries typically occur when a person or company checks your credit as part of a background check. Unlike hard inquiries, soft inquiries will NOT affect your credit scores. They may or may not be recorded in your credit reports, depending on the credit bureau.

Upload Current Policy

This is not required. However, if you would like us to quote a direct comparison to your current policy, please upload it here. This will save a lot of time.