Name
Street
City
State/Zip Code
E-Mail Address
Telephone Number
Current
Carrier Information
Present Insurance Company
Current Liability Limits
Select from the list below...
$500,000 Combined Single Limit
$300,000 Combined Single Limit
$100,000 Combined Single Limit
$60,000 Combined Single Limit
$250,000/person, $500,000/accident, $100,000 property damage
$100,000/person, $300,000/accident, $50,000 property damage
$50,000/person, $100,000/accident, $25,000 property damage
$25,000/person, $50,000/accident, $10,000 property damage
Expiration date of your current
automobile policy
Current Premium (if known)
Have you had at least 6 months of continuous coverage?
Yes
No
Vehicle Description
Vehicle #1 (Year, Make &
Model)
VIN#
Vehicle #2 (Year, Make &
Model)
VIN#
Vehicle #3 (Year, Make &
Model)
VIN#
Vehicle
Use
Vehicle #1
Driven to work
Pleasure
Business Use
Farm Use
If Driven To Work...How Many
Miles 1 Way:
If Business...Describe:
Vehicle #2
Driven to work
Pleasure
Business Use
Farm Use
If Driven To Work...How Many
Miles 1 Way:
If Business...Describe:
Vehicle #3
Driven to work
Pleasure
Business Use
Farm Use
If Driven To Work...How Many
Miles 1 Way:
If Business...Describe:
Driver
Information Please list all licensed drivers in the household
Driver #1 Name
Date of Birth
Drivers License #
Social Security #
Select Gender...
Male
Female
Select Status...
Married
Single
If student, do they have a
Yes
No
Have you completed an accident
Yes
No
Number
of years licensed?
less then 1 year
less then 2 years
less then 3 years
more then 3 years
Any Claims/Tickets/Accidents
Any Major Violations (DWI,
Reckless Driving, Speeding 15 mph Over Limit,
etc.?
Driver #2 Name
Date of Birth
Drivers License #
Social Security #
Select Gender...
Male
Female
Select Status...
Married
Single
If student, do they have a
Yes
No
Have you completed an accident
Yes
No
Number
of years licensed?
less then 1 year
less then 2 years
less then 3 years
more then 3 years
Any Claims/Tickets/Accidents
Any Major Violations (DWI,
Reckless Driving, Speeding 15 mph Over Limit,
etc.?
Driver #3 Name
Date of Birth
Drivers License #
Social Security #
Select Gender...
Male
Female
Select Status...
Married
Single
If student, do they have a
Yes
No
Have you completed an accident
Yes
No
Number
of years licensed?
less then 1 year
less then 2 years
less then 3 years
more then 3 years
Any Claims/Tickets/Accidents
Any Major Violations (DWI,
Reckless Driving, Speeding 15 mph Over Limit,
etc.?
Driver #4 Name
Date of Birth
Drivers License #
Social Security #
Select Gender...
Male
Female
Select Status...
Married
Single
If student, do they have a
Yes
No
Have you completed an accident
Yes
No
Number
of years licensed?
less then 1 year
less then 2 years
less then 3 years
more then 3 years
Any Claims/Tickets/Accidents
Any Major Violations (DWI,
Reckless Driving, Speeding 15 mph Over Limit,
etc.?
Coverage Desired
Liability Coverage and Limits
Select from the list below...
$500,000 Combined Single Limit
$300,000 Combined Single Limit
$100,000 Combined Single Limit
$60,000 Combined Single Limit
$250,000/person, $500,000/accident, $100,000 property damage
$100,000/person, $300,000/accident, $50,000 property damage
$60,000/person, $100,000/accident, $25,000 property damage
$25,000/person, $50,000/accident, $10,000 property damage
NY No-Fault Limits
$50,000
$75,000
$100,000
$150,000
OBEL Yes No
Uninsured/Underinsured
Motorist Coverage(s)
Select from the list below...
$500,000/person combined single limit
$100,000/person combined single limit
$250,000/person, $500,000/accident
$100,000/person, $300,000/accident
$50,000/person, $100,000/accident
$25,000/person, $50,000/accident
Comprehensive/Other
Than Collision
Deductible Vehicle #1
$50
$100
$200
$250
$500
$1000
FULL GLASS Yes No
Deductible Vehicle #2
$50
$100
$200
$250
$500
$1000
FULL GLASS Yes No
Deductible Vehicle #3
$50
$100
$200
$250
$500
$1000
FULL GLASS Yes No
Collision
Vehicle #1
Select from the list below...
NONE
$100 deductible
$200 deductible
$250 deductible
$500 deductible
$1,000 deductible
Vehicle #2
Select from the list below...
NONE
$100 deductible
$200 deductible
$250 deductible
$500 deductible
$1,000 deductible
Vehicle #3
Select from the list below...
NONE
$100 deductible
$200 deductible
$250 deductible
$500 deductible
$1,000 deductible
Towing Coverage Yes No
Rental Reimbursement Coverage Yes No
Please enter any questions or
comments :
Do you request an umbrella
liability quote*? Yes No
*A
personal umbrella liability policy is an excess policy that
provides LIABILITY over-and-above the current limits of your
existing automobile, homeowner, watercraft, snowmobile (etc)
liability coverage. It also can fill in any gaps you may
have in your primary policies. The umbrella limit starts at
$1Million and can be increased at your option. Annual
premium can be as low as $200 (depending on your underlying
exposures). That's a great price for a good night's sleep,
knowing your liability exposures are well cared for.
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