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Insured Information

Insured Name *
Address
City
State/Province
Zip/Postal Code
Phone
Date of Birth
Social Security Number
Email *
Do you own your own home?	Yes No

Current Insurance

Do you presently have Auto Insurance?	Yes No
Company Name
Renewal Date
Annual Premium
Have you been cancelled or non-renewed in the past 3 years?	Yes No

Coverages

Bodily Injury LiabilityBodily injury is the physical injury or damage to the body of an individual or the destroying of it. It does not include the inanimate injury such as hurt feelings, embarrassment, false arrest, libel, slander, etc.
Property Damage LiabilityIn insurance this generally refers to damage to physical property of others as distinct from personal injuries to others. It is commonly written in conjunction with such public liability or personal injury insurance.
Medical Payments
Personal Injury Protection or PIPAll injuries to the person, including non-physical injuries such as false arrest, libel, slander, defamation of character, etc.	Yes No
Uninsured Motorist Bodily InjuryIf the insured's is injured in an accident by a third party who is responsible and the court awards judgment in favor of the insured, but since the third party is uninsured and is unable to make good the payment, the insured's company will make such payment if coverage provided under their policy.
Underinsured Motorist Bodily InjuryIf the insured is injured in an accident by a third party who is responsible and the court awards judgment in favor of the insured, but since the third party is not insured enough to cover the loss and is unable to make good the payment, the insured's company will make such payment if coverage provided under their policy.
Underinsured Motorist Property Damage 3,500	Yes No
Comprehensive DeductibleThat type of automobile insurance covering damage to the vehicle of the insured from causes other than collision - such as flood, hail, explosion, theft, windstorm, etc. Generally excludes Collision and Upset which is required to be insured separately.
Collision DeductibleThe type of automobile insurance that pays for the damage to the motor vehicle, caused by upset of the car or collision of the vehicle with another car or object, whether or not the accident is the fault of the insured. Such payments are usually subject to a deductible amount.
Rental ReimbursementInsurance protection against loss due to the inability to use a property because of its damage or destruction. For example, a car may be badly damaged in an accident and take two weeks to repair. The insured may need to rent another car during that time. Therefore the loss is not only the damage to the vehicle but for the loss of use of it until the insured is put back into the position he/she was before the incident.	Yes No
Towing & LaborTowing is Labor coverage provides coverage for Lock out service, Roadside Assistance, Towing, etc if the auto has a mechanical breakdown or in an accident, this coverage is a reimbursement coverage.	Yes No

Licensed Drivers

1. (Primary Driver)
Name on License
License State
License Number
Date of Birth
Gender	Male Female
Marital Status	Married Single Divorced Widowed
Relationship to Applicant
Occupation
Good StudentNot applicable with all Companies. This can be a discount based on a young drivers grades. GPA required is 3.0 or greater. Discount amount varies with each Company.	Yes No
Driver TrainingNot applicable with all Companies. Driver is required to be at least 55 years old and must have completed a Defensive Driver Training Course. Discount amount varies with each Company.	Yes No
Tickets and Accidents (last 5 years)

2.
Name on License
License State
License Number
Date of Birth
Gender	Male Female
Marital Status	Married Single Divorced Widowed
Relationship to Applicant
Occupation
Good Student	Yes No
Driver TrainingNot applicable with all Companies. Driver is required to be at least 55 years old and must have completed a Defensive Driver Training Course. Discount amount varies with each Company.	Yes No
Tickets and Accidents (last 5 years)

Other Drivers

Please provide the names and birthdates of any other residents in your household licensed to drive.

	Name	Date of Birth	Drivers License Number
1.
2.
3.

Vehicle(s) Information

1.
Year
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive	Yes No
Alarm System	Yes No
Air Bags	Yes No
Anti-Lock Brakes	Yes No
Auto-Seatbelts	Yes No

2.
Year
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive	Yes No
Alarm System	Yes No
Air Bags	Yes No
Anti-Lock Brakes	Yes No
Auto-Seatbelts	Yes No

3.
Year
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive	Yes No
Alarm System	Yes No
Air Bags	Yes No
Anti-Lock Brakes	Yes No
Auto-Seatbelts	Yes No

4.
Year
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive	Yes No
Alarm System	Yes No
Air Bags	Yes No
Anti-Lock Brakes	Yes No
Auto-Seatbelts	Yes No

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Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.