APPLICANT INFORMATION:

Request Date:

Applicants Name:

Street Address:

City:

County:

State:

Zip Code:

Home Phone:

Work Phone:

Fax Number:

E-mail Address:

Currently Insured?

yes no

If Insured - Name of Company:

Full Name:

Date of Birth:

Sex:

Male Female

Male Female

Status:

Married Single

Married Single

Driver Training:

yes no

yes no

Driving Experience:

Over 5 Years 3-5 Years 1-2 Years None

Over 5 Years 3-5 Years 1-2 Years None

Social Security Number:

Number of Minor Moving Tickets such as Speeding or Stop Signs for the Past 3 Years:

3 2 1 None

3 2 1 None

Number of Major Tickets such as DWI, DUI, Racing, Reckless Driving for the past 5 years:

3 2 1 None

3 2 1 None

Number of Not At-Fault Accidents for the past 3 Years:

2 1 None

2 1 None

Number of AT-FAULT Accidents past 3 years:

2 1 None

2 1 None

Number of Insurance Claims for the past 3 years.

2 1 None

2 1 None

Auto Descriptions:

Vehicle # 1

Vehicle # 2

Year:

Make:

Model:

Style:

2 Door 4 Door Van Pick Up Convertable

2 Door 4 Door Van Pick Up Convertable

Drive:

None 2 Wheels 4 Wheels

None 2 Wheels 4 Wheels

Air Bags:

None Driver Only Both Sides

None Driver Only Both Sides

Anti Lock Breaks

None 2 Wheels 4 Wheels

None 2 Wheels 4 Wheels

Alarm:

None Manufacturer After Market

None Manufacturer Aftermarket

Use:

Commute Pleasure In Business

Commute Pleasure In Business

Annual Mileage:

0-5000 5000-7500 7500-10000 10000-15000 Over 15000

0-5000 5000-7500 7500-10000 10000-15000 Over 15000

Miles to Work one way:

COVERAGE REQUEST:

Liability - Bodily Injury to Others:

$20,000 / $40,000 $25,000 / $50,000 $50,000 / $100,000 $100,000 / $300,000

Liability - Property Damage of Others:

$ 10,000 $ 15,000 $ 25,000 $ 50,000 $100,000

Uninsured Motorist Liability:

$20,000 / $40,000 $25,000 / $50,000 $50,000 / $100,000 $100,000 / $300,000

Medical Payments to Others Limit:

500 1,000 5,000 10,000 None

Physical Damage Coverage:

Vehicle # 1

Vehicle # 2

Comprehensive (Fire-Theft):

yes no

yes no

Comprehensive Deductible:

250 500 1,000 None

250 500 1,000 None

Collision Coverage:

yes no

yes no

Collision Deductible:

250 500 1,000 None

250 500 1,000 None

Full Glass Coverage (No Deductible)

yes no

yes no

Rental Reimbursement:

$ 15/Day $ 25/Day None

$ 15/Day $ 25/Day None

Towing:

$ 50 $ 75 None

$ 50 $ 75 None

REMARKS