Automobile Quote Form

Although our agency feels it is important to personally speak with you and evaluate your insurance needs, we also understand your needs for convenience and timeliness.  In order to provide you with a quote, our agency needs you to complete the following form.  Please feel free to contact us with any questions or if you desire more personalized attention. 

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State
Zip
County
Township/Boro
Work Phone
Home Phone
FAX
E-mail

How long have you lived at your current address: 
    If less than 1 year, please list your prior address: 

Please provide information on all licensed drivers in the household and away at school or military:

#	Driver Name	Date of Birth	Marital Status	Sex	Driver Training Discount
1			Single Married Seperated Divorced	Male Female	None Yes
2			Single Married Seperated Divorced	Male Female	None Yes
3			Single Married Seperated Divorced	Male Female	None Yes
4			Single Married Seperated Divorced	Male Female	None Yes

Please provide information on your vehicles to be insured:

#	Year	Make & Model	VIN #	Restraint System	Alarm System
1				None 1 Air Bag 2 Air Bags 3 Air Bags Automatic Seat Belts	None Yes

Automatic Brakes (ABS)	Primary Driver of Vehicle	Use of Vehicle, Miles to Work One Way
None Yes	Driver 1 Driver 2 Driver 3 Driver 4	Pleasure Work < 3 Work 3 to 9 Work 10 to 15 Work > 15 Delivery Sales Territory Contractor Real Estate Other

#	Year	Make & Model	VIN #	Restraint System	Alarm System
2				None 1 Air Bag 2 Air Bags 3 Air Bags Automatic Seat Belts	None Yes

Automatic Brakes (ABS)	Primary Driver of Vehicle	Use of Vehicle, Miles to Work One Way
None Yes	Driver 1 Driver 2 Driver 3 Driver 4	Pleasure Work < 3 Work 3 to 9 Work 10 to 15 Work > 15 Delivery Sales Territory Contractor Real Estate Other

#	Year	Make & Model	VIN #	Restraint System	Alarm System
3				None 1 Air Bag 2 Air Bags 3 Air Bags Automatic Seat Belts	None Yes

Automatic Brakes (ABS)	Primary Driver of Vehicle	Use of Vehicle, Miles to Work One Way
None Yes	Driver 1 Driver 2 Driver 3 Driver 4	Pleasure Work < 3 Work 3 to 9 Work 10 to 15 Work > 15 Delivery Sales Territory Contractor Real Estate Other

#	Year	Make & Model	VIN #	Restraint System	Alarm System
4				None 1 Air Bag 2 Air Bags 3 Air Bags Automatic Seat Belts	None Yes

Automatic Brakes (ABS)	Primary Driver of Vehicle	Use of Vehicle, Miles to Work One Way
None Yes	Driver 1 Driver 2 Driver 3 Driver 4	Pleasure Work < 3 Work 3 to 9 Work 10 to 15 Work > 15 Delivery Sales Territory Contractor Real Estate Other

Please provide information on coverage's desired:

Vehicle Coverage's	Vehicle #1	Vehicle #2	Vehicle #3	Vehicle #4
Comprehensive Deductible	No Coverage 0 50 100 250 500 1000	No Coverage 0 50 100 250 500 1000	No Coverage 0 50 100 250 500 1000	No Coverage 0 50 100 250 500 1000
Collision Deductible	No Coverage 100 250 500 1000	No Coverage 100 250 500 1000	No Coverage 100 250 500 1000	No Coverage 100 250 500 1000
Rental Reimbursement	No Coverage $15/day $20/day $25/day $30/day	No Coverage $15/day $20/day $25/day $30/day	No Coverage $15/day $20/day $25/day $30/day	No Coverage $15/day $20/day $25/day $30/day
Towing	No Coverage $25 $50 $75 Unlimited	No Coverage $25 $50 $75 Unlimited	No Coverage $25 $50 $75 Unlimited	No Coverage $25 $50 $75 Unlimited
Loan/Lease Gap Coverage	No Coverage Yes	No Coverage Yes	No Coverage Yes	No Coverage Yes

Liability Limits
Bodily Injury Split Limit	$15,000/30,000 $25,000/50,000 $50,000/100,000 $100,000/300,000 $250,000/500,000	Property Damage	$5000 $10,000 $25,000 $50,000 $100,000 $250,000

or Bodily Injury Single Limit	No Coverage $35,000 $50,000 $100,000 $300,000 $500,000
Tort Option	Full Tort Limited Tort
Uninsured Motorist Bodily Injury (UM)	No Coverage $15,000/30,000 $25,000/50,000 $50,000/100,000 $100,000/300,000 $250,000/500,000 $35,000 $50,000 $100,000 $300,000 $500,000   Stacked Non-Stacked
Underinsured Motorist Bodily Injury (UIM)	No Coverage $15,000/30,000 $25,000/50,000 $50,000/100,000 $100,000/300,000 $250,000/500,000 $35,000 $50,000 $100,000 $300,000 $500,000   Stacked Non-Stacked
Medical Expense	$5000 $10,000 $25,000 $50,000 $100,000
Income Loss	No Coverage $1,000 Monthly/$5,000 Total $1,000 Monthly/$15,000 Total $1,500 Monthly/$25,000 Total $2,500 Monthly/$50,000 Total
Funeral Expense	No Coverage $1,500 $2,500
Accidental Death	No Coverage $5,000 $10,000 $25,000
Optional Combination First Party Benefits	No Coverage $50,000 $100,000 $177,500
Optional Extraordinary Medical Benefits	No Coverage $100,000 $300,000 $500,000 $1,000,000

Please list all motor vehicle incidents in the last 3 years for all drivers in the household (This includes moving violations, suspensions, accidents or insurance claims of any kind.)  Please be as detailed as possible.  List the driver, date of incident, description and for claims list how much money was paid by the insurance company.  If there is none, please state "None".

Do you currently have insurance coverage in force?  Yes No
If Yes, please list your insurance company and policy effective dates:  
Have you maintained continuous coverage, with no lapses, for the last 6 months?  Yes No
If you currently have no coverage, when was the last time you did? 
Have you filed or declared bankruptcy in the last 5 years?  No Yes

Please list any additional comments below which you feel may influence your insurance quote:

By submitting this information to our agency for a quote, you understand there is no coverage in force.  You also understand there may be additional information needed in order to secure a quote and we will contact you for this information.

After submitting the form for us to review, we will generally respond within 24 hours.  Please let us know how you would like us to contact you:  E-mail  Phone  Fax  US Mail