Insurance Division

Competitive Rates

Independent Agents for:
  • Auto
  • Home
  • Farm
  • Business
  • Life
  • Health
  • Allstate Insurance

  • Badger Mutual

  • General Causality

  • Germantown Mutual

  • Safeco Insurance


Auto Quote Request Form

Applicant Information:

  Name . Spouse
  Address zip code
  City State
  e-mail phone
Please contact me via: e-mail, Telephone, or Post Office
Insured Spouse Youth#1 Youth#2
Date of Birth
Social Security # 
Drivers License # 
Employer/Years
Home Phone
Work Phone
Prior Insurance Company  Expiration Date # Years

Vehicle Information:

Vehicle #1 Year Make Model
Vin #
#Doors Use Miles 1 way to work Air bag ABS

Vehicle #2 Year Make Model
Vin #
#Doors Use Miles 1 way to work Air bag ABS

Vehicle #3 Year Make Model
Vin #
#Doors Use Miles 1 way to work Air bag ABS

Accidents or violations in last five years, if any:

Month 
Year 
Month 
Year

Coverages Desired:

.  Vehicle #1   Vehicle #2   Vehicle #3 
Liability Limits 
Medical Payments 
Accidental Death
Uninsured Motorist 
Comprehensive Deductible
Collision Deductible 
Towing 
Auto Rental 

Additional Comments:

 Please be sure all information on this form is correct before submitting for quote.


This form is hosted on a secure server for protection of your personal information.
Information provided by your on this form will be kept confidential. 

Dodgeville Office:

158 N. Iowa St
Dodgeville, WI. 53533
Phone: 608-935-2396
Toll Free: 877-253-7878
Fax: 608-935-9714

Mineral Point Office:

241 High St.
Mineral Point, WI. 53565
Phone: 608-987-2142
Toll Free 877-235-4573
Fax: 608-987-3936 

info@pottertonrule.com