AUTO QUOTE
DRIVER INFORMATION:
(all household residents with a drivers license)
Name
Age
Driving History
1
Have you had any accidents, violations or suspensions in the past three years?
Yes
No
2
Have you had any accidents, violations or suspensions in the past three years?
Yes
No
3
Have you had any accidents, violations or suspensions in the past three years?
Yes
No
4
Have you had any accidents, violations or suspensions in the past three years?
Yes
No
Address:
Address 2:
City:
State:
Zip:
Phone:
Work Phone:
Email:
Vehicle1*
Vehicle2
Vehicle3
Year*
(i.e. 1998)
Make*
(i.e. Chevrolet)
Model/Trim
(i.e. Cavalier LS Convertible)
Body Style
(i.e. 2-door)
Cylinders
Select
4
6
8
10
12
Select
4
6
8
10
12
Select
4
6
8
10
12
Passive Restraints*
Select
NONE
1 airbag
2 airbags
Auto Seatbelts
Select
NONE
1 airbag
2 airbags
Auto Seatbelts
Select
NONE
1 airbag
2 airbags
Auto Seatbelts
Anti-Theft Device*
Select
None
active (i.e. Lo-jack)
passive (i.e. Car alarm)
Select
None
active (i.e. Lo-jack)
passive (i.e. Car alarm)
Select
None
active (i.e. Lo-jack)
passive (i.e. Car alarm)
One-Way
Miles
to Work
Total
Annual
Miles
Limit
of
Liability
$
Select
State Minimum
20/40K
50/100K
100/300K
250/500K
$
Select
State Minimum
20/40K
50/100K
100/300K
250/500K
$
Select
Minimum
20/40K
50/100K
100/300K
250/500K
Limit of
Property
Damage
$
Select
State Minimum
15K
25K
50K
100K
$
Select
Minimum
15K
25K
50K
100K
$
Select
Minimum
15K
25K
50K
100K
Comprehensive
Deductible
$
Select
NONE
0
100
200
250
500
1000
$
Selected
NONE
0
100
200
250
500
1000
$
Select
NONE
0
100
200
250
500
1000
Collision
Deductible
$
Select
NONE
0
100
200
250
500
1000
$
Select
NONE
0
100
200
250
500
1000
$
Select
NONE
0
100
200
250
500
1000
Has any driver had any accidents or violations in the past three years?
Yes
No
If
yes
, please explain::
You may also FAX your declaration page to (724) 443-1470
