GENERAL INFORMATION

Name   Address

Daytime Phone    Evening

E-Mail Address   FAX

Are you presently insured? No Yes   Years Insured

VEHICLE INFORMATION

Vehicle 1 Yr   Make   Model

Use: Miles Driven to Work/School 1-Way: If Business use so state

Vehicle 2 Yr   Make   Model

Use: Miles Driven to Work/School 1-Way: If Business use so state

Vehicle 3 Yr   Make   Model

Use: Miles Driven to Work/School 1-Way: If Business use so state

Vehicle 4 Yr   Make   Model

Use: Miles Driven to Work/School 1-Way: If Business use so state

Vehicle 5 Motor Home Yr   Make    

Model   Cost New   Length

DRIVER INFORMATION

Driver of Vehicle #   Date of Birth   Sex Male Female   

Marital Status Single Married    Past 3 years tickets accidents

Driver of Vehicle #   Date of Birth   Sex Male Female

Marital Status Single Married Past 3 years tickets accidents

Driver of Vehicle #   Date of Birth    Sex Male Female

Marital Status Single Married Past 3 years tickets accidents

Driver of Vehicle #   Date of Birth   Sex Male Female  

Marital Status Single Married Past 3 years tickets accidents

Driver of Vehicle #   Date of Birth   Sex Male Female

Marital Status Single Married Past 3 years tickets accidents

Accident - Who was at fault

Any Person Injured No Yes

If full time student does He or She get a "B" average of better No Yes

Student Name

OCCUPATIONAL DISCOUNTS

Architect No Yes   BS Science Degree No Yes   CPA No Yes

Dentist No Yes   Engineer No Yes   Firefighter No Yes   

Lawyer/Judge No Yes   Physician No Yes   Police Person No Yes

Registered Nurse No Yes

COVERAGE

Liability 15/30 20/40 25/50 30/60 35/70 50/100 100/300 250/500 500/500   Property 5,000 10,000 15,000 20,000 25,000 40,000 50,000 100,000 500,000

Uninsured/Underinsured Motorist 15/30 25/50 30/60 35/70 50/100 100/300 250/500 500/500

UM Property Damage No Yes   Medical 500 1,000 2,000 5,000 10,000 100,000

Comprehensive Deductible Full 50 100 120 150 200 240 250 500 1,000 1,000/10% 2,500 5,000   Collision Deductible 25 50 60 100 120 150 200 240 250 500 1,000 1,000/10% 2,500 5,000

Towing/Road Service No Yes   Loss of Use $15/day Max. $300 $25/day Max. $500 $50/day Max. $1,000

Would you like the quote delivered by Personal Contact Mail E-Mail Fax

Additional Information