AUTOMOBILE INSURANCE QUOTATION FORM

Information submitted will be held confidential and will be used for quote purposes only.
Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreeent to provide coverage under any insurance policy.

PERSONAL INFORMATION

First Name :
Last Name:
E-Mail address:
Daytime Phone Number:
Evening Phone Number:
Fax Number:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail   E-mail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address:
City:
State:
Zip code:
Do you currently own your home, or rent?	Own Rent
Driver's license number:
Social security number:

DRIVER INFORMATION

	Name:	Relationship to applicant:	Sex:	Marital status:	Driver's age:	Which vehicle does he/she drive?	Percent use:
Driver #1		Select One Self Spouse Child Parent Other	Male     Female	Married Single		Select One Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Driver #2		Select One Self Spouse Child Parent Other	Male     Female	Married Single		Select One Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Driver #3		Select One Self Spouse Child Parent Other	Male     Female	Married Single		Select One Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Driver #4		Select One Self Spouse Child Parent Other	Male     Female	Married Single		Select One Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4

DRIVER HISTORY

Currently insured with (company name not agency):

Have you or any other driver in your household:

Had a ticket in the last 3 years? Had a license suspended or revoked in the last 6 years? Had a financial responsibility filing in the last 6 years? Made any claims in the last 5 years? Yes No Yes No Yes No Yes No

If you answered yes to any of the above questions, please explain:

VEHICLE #1 INFORMATION

Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
Select One Driver #1 Driver #2 Driver #3 Driver #4		Yes No	Days Weeks	Miles

Is the vehicle in any way modified or customized?	Is there any existing damage to the vehicle?
Yes No	Yes No

If vehicle is kept at an address other than that listed above, please indicate below:

Address: City:   State:   Zip:

VEHICLE #2 INFORMATION

Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
Select One Driver #1 Driver #2 Driver #3 Driver #4		Yes No	Days Weeks	Miles

Is the vehicle in any way modified or customized?	Is there any existing damage to the vehicle?
Yes No	Yes No

If vehicle is kept at an address other than that listed above, please indicate below:

Address: City:   State:   Zip:

VEHICLE #3 INFORMATION

Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
Select One Driver #1 Driver #2 Driver #3 Driver #4		Yes No	Days Weeks	Miles

Is the vehicle in any way modified or customized?	Is there any existing damage to the vehicle?
Yes No	Yes No

If vehicle is kept at an address other than that listed above, please indicate below:

Address: City:   State:   Zip:

VEHICLE #4 INFORMATION

Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
Select One Driver #1 Driver #2 Driver #3 Driver #4		Yes No	Days Weeks	Miles

Is the vehicle in any way modified or customized?	Is there any existing damage to the vehicle?
Yes No	Yes No

If vehicle is kept at an address other than that listed above, please indicate below:

Address: City:   State:   Zip:

COVERAGE OPTIONS

Bodily injury liability:	Select One $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000
Property damage liability:	Select One $50,000 $100,000 $250,000 $500,000
Underinsured motorist-bodily injury:	Select One None $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000
Underinsured motorist-property damage:	Select One None $25,000 $50,000 $100,000 $250,000
Medical-personal injury protection:	Select One None $10,000 $25,000 $35,000
Accidental death:	Select One None 1 at $5,000 1 at $10,000 2 at $5,000 2 at $10,000

COVERAGE DEDUCTIBLES

	Comprehensive deductible:	Collision deductible:	Towing coverage deductible:
Vehicle #1	Select One $100 $200 $500	Select One $200 $250 $500 $1,000	Select One Not interested $50 $100 $200
Vehicle #2	Select One $100 $200 $500	Select One $200 $250 $500 $1,000	Select One Not interested $50 $100 $200
Vehicle #3	Select One $100 $200 $500	Select One $200 $250 $500 $1,000	Select One Not interested $50 $100 $200
Vehicle #4	Select One $100 $200 $500	Select One $200 $250 $500 $1,000	Select One Not interested $50 $100 $200

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?

Copyright 2001 © The Mines Press