Name

Address

County

E-mail

Vehicle Information

Vehicle #1: (Year, Make & Model)

Vehicle #2: (Year, Make & Model)

Driver Information - Driver #1

Driver Name

Which vehicle is this person the principle operator of?
Vehicle #1  Vehicle #2

Driver Information - Driver #2

Driver Name

Which vehicle is this person the principle operator of?
Vehicle #1  Vehicle #2

Coverages

Part 1 - Bodily Injury Injury to Others
$20,000 per person, $40,000 per accident (Mandatory)

Part 2 - Personal Injury Protection
$8000 (Mandatory)

Part 3 - Uninsured Motorist
$20,000 per person, $40,000 per accident
$25,000 per person, $50,000 per accident
$50,000 per person, $100,000 per accident
$100,000 per person, $300,000 per accident
$250,000 per person, $500,000 per accident

Part 4 - Property Damage (Each Accident)
$25,000  $50,000  $100,000

Part 5 - Optional Bodily Injury
$20,000 per person, $40,000 per accident
$25,000 per person, $50,000 per accident
$50,000 per person, $100,000 per accident
$100,000 per person, $300,000 per accident
$250,000 per person, $500,000 per accident

Part 6 - Medical Payments
No Coverage  $5,000  $10,000  $15,000  $25,000

Part 7 - Collision Coverages
Collision Coverage Deductibles

Part 9 - Comprehensive Coverage
Comprehensive Coverage Deductibles

Part 10 - Substitute Transportation

Vehicle #1
No Coverage
$15 per day, maximum $450
$30 per day, maximum $900

Vehicle #2
No Coverage
$15 per day, maximum $450
$30 per day, maximum $900

Part 11 - Towing

Part 12 - Underinsured Motorist

$20,000 per person, $40,000 per accident
$25,000 per person, $50,000 per accident
$50,000 per person, $100,000 per accident
$100,000 per person, $300,000 per accident
$250,000 per person, $500,000 per accident

Safety Features

Number of Air bags Vehicle #1
None  One  Two

Number of Air bags Vehicle #2
None  One  Two

Automatic Seat Belts
Vehicle #1 Vehicle #2

Additional Information

Is any vehicle driven under 7,500 miles per year? Please comment including estimated annual miles driven:

Do you currently have insurance?
Yes No

Name of Current Insurance Company

Current Policy Expiration Date, if known

Some home insurers provide discounts if the auto and home insurance is packaged together.

Do you own a home?
Yes No

If so, please provide the name of the home insurance company, if known

Comments