Potter Agency, LLC
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Secure Add Driver Request Form

 
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Driver 1

 
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Driver 2

 
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Driver 3

 
Driver 3 Name:
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Accidents Within 5 Years?
Violations Within 5 Years?
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Eligible For Defensive Driver Discount?
Eligible For Drivers Ed Discount?

Driver 4

 
Driver 4 Name:
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Accidents Within 5 Years?
Violations Within 5 Years?
SR22 Filing?
Eligible For Good Student Discount?
Eligible For Defensive Driver Discount?
Eligible For Drivers Ed Discount?

Driver 5

 
Driver 5 Name:
First Last
Driver 5 Date of Birth:
Driver 5 Gender:
Marital Status:
Relation to Applicant:
License Status:
License State:
Occupation Industry:
Occupation Title:
Age Licensed:
Accidents Within 5 Years?
Violations Within 5 Years?
SR22 Filing?
Eligible For Good Student Discount?
Eligible For Defensive Driver Discount?
Eligible For Drivers Ed Discount?
Website Disclaimer - Review Carefully:

This information is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.
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2115 E Clairemont Ave Ste 1 Eau Claire, WI 54701 | Phone: 715-552-3511 | Fax: 715-552-3548 | Contact Us | Get Map
8435 W Bryn Mawr Ave #1NW Chicago, Il 60631 | Phone: | Contact Us | Get Map
5 W John Street Rice Lake, Wi 54868 | Phone: 7152344887 | Contact Us | Get Map
Located in Eau Claire, Wisconsin; Chicago, Illinois; and, Rice Lake, Wisconsin. We also serve the Altoona, Baldwin, Chippewa Falls, Hudson, and Menomonie areas. - Licensed in Illinois,  Minnesota,  Virginia and  Wisconsin
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