Vern Fonk Insurance
Vern Fonk
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Get a FREE rate quote today with Vern Fonk Insurance. Just fill out our simple form and sit back and wait to be contacted by one of our representatives.
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STOP! Our internet customers can go to the front of the line!

Vern Fonk Insurance gives our internet customers special attention by sending them to the front of the line. Please call during business hours: 9 am - 6 pm, Monday through Friday and 9 am - 2 pm on Saturday for immediate assistance on your auto and home insurance needs.To make an appointment today, call 1 (800) 654-7722!

Internet customers only!


Please fill out the form below and we will contact you with an insurance quote and answer any questions you have. Required fields are marked with a * , however to receive the most accurate quote we prefer that you answer all the questions.

*Before starting: Please select the city nearest you!

Tell Us About Yourself
*First Name:
Middle Initial:
*Last Name:
*Day Phone:    –   ext.
*Address:
*City:
*State:  
*Zip code:
Cell Phone:    –   ext.
*Email:
*Gender:
*Date of Birth (mm/dd/yyyy): / /
*Marital Status:
Occupation:
*Are you a Home Owner? Yes     No
How many years have you been licensed? /yrs
Current Insurance Company (if applicable):
How long have you been with your current provider: /yrs /mo

How did you hear about us?
*How did you hear about us?

Tell Us About Your Spouse (if applicable)
*Spouse's First Name:
Spouse's Last Name:
*Gender:
*Date of Birth (mm/dd/yyyy): / /
Occupation:
*How many years have your spouse been licensed? /yrs
Current Insurance Company (if applicable):
How long has your spouse been with his/her current provider: /yrs /mo

Additional Drivers
If you are insuring drivers other than yourself including your spouse, please fill out their information below. If you need to insure more than 4 drivers, please make note in the comments area at the bottom of the form.
First Name Date Of Birth Licensed
 /  /   /yrs
 /  /  /yrs
 /  /  /yrs
 /  /  /yrs

Driving Violations
*How Many Violations or Accidents have you had in the last 3 years?
Please specify violations for the drivers above. If there are more than 8 violations, please make note in the comments area at the bottom of the form.
Driver's Name Violation Date of Violation
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 
 /   / 

Need A SR-22?
If you need an SR-22 filing, please indicate the State here.

Tell Us About Your Vehicles
*If you have more than 3 vehicles, please make note in the comments area at the bottom of the form.

Vehicle One
*Year:
*Make:
*Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?
*Comprehensive (DEDUCTIBLE):
*Collision (DEDUCTIBLE):

Vehicle Two
Year:
Make:
Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?
*Comprehensive (DEDUCTIBLE):
*Collision (DEDUCTIBLE):

Vehicle Three
Year:
Make:
Model:
Sub-Model (ie: LX, GTI):
Vehicle Identification Number (VIN):
How many doors? 2 doors     4 doors
Convertible: Yes     No
4x4: Yes     No
Number of cylinders:
Do you have a loan on this car? Yes     No
If yes, who is it through?