HEAD OF HOUSEHOLD NAME, DOB, SSN, DRIVERS LICENSE # AND

     DRIVER 1                                  DRIVER 2 (not req.)

Name

Name

Address

Address

City

City

State

Zip

State

Zip

Work Phone

Work Phone

As part of underwriting process some information may be confirmed through Consumer Reports which may include credit information.         
These reports provide information to assist with risk evaluation and placement.  Your premiums are also determined, in part, by the information contained in these reports.

This will not affect your credit history in any way.

Home Phone

Home Phone

E-mail:

E-mail:

Current Ins.

Current Ins.

Current Ins. Expires

Current Ins. Expires

Age

Age

Status

Status

How far 1 way to work

How far 1 way to work

Please list all:
Accidents in the past 3 [THREE] yrs.,
Minor Cites (Speeding, Stop Sign, etc.) in the Past 3 [THREE] yrs.,
Major Cites (DWI, BAC C&I) in the past 5 [FIVE] Yrs.

Please list all:
Accidents in the past 3 [THREE] yrs.,
Minor Cites (Speeding, Stop Sign, etc.) in the Past 3 [THREE] yrs.,
Major Cites (DWI, BAC C&I) in the past 5 [FIVE] Yrs.

     VEHICLE 1                               VEHICLE 2 (not req.)

Year

Year

Make

Make

Model

Model

VIN #

VIN #

Mileage

Mileage

Liters

Drive

Liters

Drive

Discounts

Discounts

2/4

2/4

Manufacturers Warranty

Manufacturers Warranty

If still covered indicate Yrs/Miles in coverage

If still covered indicate Yrs/Miles in coverage

Coverage

Coverage

Medical

BIPD/UM/UIM*

Medical

BIPD/UM/UIM*

Coll./CompDeductible

Coll./CompDeductible

(250,500,1000,2500,5k)

(250,500,1000,2500,5k)

BIPD (Bodily Injury And Property Damage) = you if you're liable for injuries or damage to other people, regardless if car is driven by you, family, or someone else with permission
UM (Uninsured Motorist) = Covers you and passengers against injuries caused by uninsured or hit-and-run motorists.
UIM (Under Insured Motorist) = Covers your damages if other motorists insurance does not cover up to the same amount as your coverage (not the same as Uninsured).
Medical = Pays for reasonable medical and funeral expenses for you and passengers  regardless of who is at fault.
Collision (Coll) = Covers accidental damage to your car caused by collision.Comprehensive = Pays for damage to your car except when it's caused by collision