AUTOMOBILE INSURANCE QUOTATION FORM   To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. 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 agreement to provide coverage under any insurance policy. PERSONAL INFORMATION Your name: First:      Last: E-Mail address: Phone numbers: Daytime: Evening: Fax: 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 Other Spouse Child Parent 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?

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