Please provide as much information as possible for us to properly prepare your insurance proposal.  

First Name       Last Name

Address   City   State    Zip

Phone      Fax      E-Mail Address      

Currently Insured NoYes-     I have had continuous insurance without lapse for Over 3 yearsLess than 3 but over 2 yearsLess than 2 but over 1 yearLess than 1 year but over 6 months6 months4 months3 months2 months1 month-  

Currently Insured with  

Married YesNo-      Are you a single parent with custody of a child? NoYes-
Bankruptcy or adverse credit in last 5 years? -noyes
Is there anything specific to your insurance needs that we need to know in order to properly prepare your proposal?

Driver 1

Name      Age 16 to 2021 to 2425 to 2930 to 49Over 50 and lookin good!Over 55 AND Retired-     Sex MaleFemale-

Licensed Less than 3 yearsOver 3 years-      If licensed less than 3 years, how many months?    

If driver is under 25, Driver is college graduate with 3.0 GPA or better.Driver attended at least 2 years colllege with 3.0 GPA or better.Driver is full time student in college with 3.0 GPA or betterDriver is full time student in high school and has a 3.0 GPA or better.-
List all moving violations, accidents and claims with auto insurance carriers incurred during the last three years

Driver 2          

Name      Age 16 to 2021 to 2425 to 2930 to 49Over 50 and lookin good!Over 55 AND Retired-     Sex FemaleMale-

Licensed Over 3 yearsLess than 3 years-      If licensed less than 3 years, how many months?    

If driver is under 25, Driver is college graduate with 3.0 GPA or better.Driver attended at least 2 years colllege with 3.0 GPA or better.Driver is full time student in college with 3.0 GPA or betterDriver is full time student in high school and has a 3.0 GPA or better.-
List all moving violations, accidents and claims with auto insurance carriers incurred during the last three years

Driver 3             

Name      Age 16 to 2021 to 2425 to 2930 to 49Over 50 and lookin good!Over 55 AND Retired-     Sex FemaleMale-

Licensed Over 3 yearsLess than 3 years-      If licensed less than 3 years, how many months?    

If driver is under 25, Driver is college graduate with 3.0 GPA or better.Driver attended at least 2 years colllege with 3.0 GPA or better.Driver is full time student in college with 3.0 GPA or betterDriver is full time student in high school and has a 3.0 GPA or better.-
List all moving violations, accidents and claims with auto insurance carriers incurred during the last three years

Driver 4             

Name      Age 16 to 2021 to 2425 to 2930 to 49Over 50 and lookin good!Over 55 AND Retired-     Sex FemaleMale-

Licensed Over 3 yearsLess than 3 years-      If licensed less than 3 years, how many months?    

If driver is under 25, Driver is college graduate with 3.0 GPA or better.Driver attended at least 2 years colllege with 3.0 GPA or better.Driver is full time student in college with 3.0 GPA or betterDriver is full time student in high school and has a 3.0 GPA or better.-
List all moving violations, accidents and claims with auto insurance carriers incurred during the last three years

Car 1      Primary Driver Driver #1 listed aboveDriver #2 listed aboveDriver #3 listed aboveDriver #4 listed aboveDriver not listed above- 

Year      Make      Model      
VIN (if available)      Anti Lock Brakes YesNo-    Air Bag YesNo-
Car owned for Do not own car, it is a leased vehicleNew car, just purchasedLess than one yearOver 1 year but less than 2 yearsOver 2 years but less than 3 yearsOver 3 years-     Miles driven per year Less than 5,0005,000 to 7,5007,500 to 10,00010,000 to 15,000Over 15,000-    
Vehicle used in business? YesNo-     Usage Pleasure onlyVehicle used for businessDriven to work/school less than 3 milesDriven to work/school 3 to 10 milesDriven to work/school 10 to 20 milesDriven to work/school over 20 miles-
Bodily Injury Liability $300,000 CSL$250,000/$500,000$100,000/$300,000$50,000/$100,000$25,000/$50,000-     Property Damage Liability $300,000$250,000$100,000$50,000$25,000-
Uninsured Motorist No Coverage Requested$300,000 CSL$100,000/$300,000$50,000/$100,000$25,000/$50,000-   Medical Payments No Coverage Requested$100,000 per person$50,000 per person$25,000 per person$10,000 per person$5,000 per person$2,000 per person$1,000 per person-    
Collision No Coverage Requested$1,000 Deductible$500 Deductible$250 Deductible-     Comprehensive (other than collision) No Coverage Requested$1,000 Deductible$500 Deductible$250 Deductible$100 Deductible-    
Car Rental No Coverage Requested$30 per day reimbursement$20 per day reimbursement-      Towing No Coverage Requested$25 reimbursement$50 reimbursement-

           

Car 2      Primary Driver Driver #1 listed aboveDriver #2 listed aboveDriver #3 listed aboveDriver #4 listed aboveDriver not listed above-

Year      Make      Model      
VIN (if available)      Anti Lock Brakes NoYes-    Air Bag NoYes-
Car owned for Over 3 yearsOver 2 years but less than 3 yearsOver 1 year but less than 2 yearsLess than one yearNew car, just purchasedDo not own car, it is a leased vehicle-     Miles driven per year Over 15,00010,000 to 15,0007,500 to 10,0005,000 to 7,500Less than 5,000-    
Vehicle used in business? NoYes-     Usage Vehicle used for businessDriven to work/school over 20 milesDriven to work/school 10 to 20 milesDriven to work/school 3 to 10 milesDriven to work/school less than 3 milesPleasure only-

Liability, Uninsured Motorist and Medical Payments coverage must be the same as on Car 1.
     
Collision No Coverage Requested$1,000 Deductible$500 Deductible$250 Deductible-     Comprehensive (other than collision) No Coverage Requested$1,000 Deductible$500 Deductible$250 Deductible$100 Deductible-    
Car Rental No Coverage Requested$30 per day reimbursement$20 per day reimbursement-      Towing No Coverage Requested$50 reimbursement$25 reimbursement-

Car 3      Primary Driver Driver #1 listed aboveDriver #2 listed aboveDriver #3 listed aboveDriver #4 listed aboveDriver not listed above-

Year      Make      Model      
VIN (if available)      Anti Lock Brakes NoYes-    Air Bag NoYes-
Car owned for Over 3 yearsOver 2 years but less than 3 yearsOver 1 year but less than 2 yearsLess than one yearNew car, just purchasedDo not own car, it is a leased vehicle-     Miles driven per year Over 15,00010,000 to 15,0007,500 to 10,0005,000 to 7,500Less than 5,000-    
Vehicle used in business? NoYes-     Usage Vehicle used for businessDriven to work/school over 20 milesDriven to work/school 10 to 20 milesDriven to work/school 3 to 10 milesDriven to work/school less than 3 milesPleasure only-

Liability, Uninsured Motorist and Medical Payments coverage must be the same as on Car 1.
     
Collision No Coverage Requested$1,000 Deductible$500 Deductible$250 Deductible-     Comprehensive (other than collision) No Coverage Requested$1,000 Deductible$500 Deductible$250 Deductible$100 Deductible-    
Car Rental No Coverage Requested$30 per day reimbursement$20 per day reimbursement-      Towing No Coverage Requested$50 reimbursement$25 reimbursement-

Car 4      Primary Driver Driver #1 listed aboveDriver #2 listed aboveDriver #3 listed aboveDriver #4 listed aboveDriver not listed above-

Year      Make      Model      
VIN (if available)      Anti Lock Brakes NoYes-    Air Bag NoYes-
Car owned for Over 3 yearsOver 2 years but less than 3 yearsOver 1 year but less than 2 yearsLess than one yearNew car, just purchasedDo not own car, it is a leased vehicle-     Miles driven per year Over 15,00010,000 to 15,0007,500 to 10,0005,000 to 7,500Less than 5,000-    
Vehicle used in business? NoYes-     Usage Vehicle used for businessDriven to work/school over 20 milesDriven to work/school 10 to 20 milesDriven to work/school 3 to 10 milesDriven to work/school less than 3 milesPleasure only-

Liability, Uninsured Motorist and Medical Payments coverage must be the same as on Car 1.
   
Collision No Coverage Requested$1,000 Deductible$500 Deductible$250 Deductible-     Comprehensive (other than collision) No Coverage Requested$1,000 Deductible$500 Deductible$250 Deductible$100 Deductible-    
Car Rental No Coverage Requested$30 per day reimbursement$20 per day reimbursement-      Towing No Coverage Requested$50 reimbursement$25 reimbursement-