Personal Auto

Number of Vehicles:
Number of Drivers:
Name:
Street Address:
Town:
State:
ZIP:
Primary Insured's Social Security Number:
Do you own a home?		Yes No
Who is your homeowners insurance carrier ?
When do you need it?
Do you have insurance now?		Yes No
If Yes, when does it expire?
If No, please choose a reason:		Not Applicable Cancelled for Non-Pay w/in Past 24 Months, NOT AT RENEWAL Cancelled for Non-Pay w/in Past 24 Months @ RENEWAL No Insurance w/in Past 24 Months Cancelled Old Policy w/in Past 24 Months & TURNED IN TAGS
COVERAGES:
Liability Limits:		$500,000 CSL $250,000/$500,000/$100,000 $300,000 CSL $100,000/$300,000/$100,000 $100,000 CSL $50,000 CSL $25,000/$50,000/$25,000 $25,000 CSL $15,000/$30,000/$5,000
Tort Threshold:		Limited / Verbal Unlimited / Zero
VEHICLE #1:
Vehicle Manufacturer:
Vehicle Model ( Include Model # ):
Vehicle Year:
Vehicle Type:		2 Door Automobile or SUV			4 Door Automobile or SUV
		2 Door Truck w/Standard Cab			2 Door Truck w/Extd Cab
		3 Door Truck			4 Door Truck/Quad Cab
Vehicle V.I.N. Number:
How many miles are on this vehicle?
How many miles is this vehicle driven per year?
Vehicle Options, Safety Equipment, Etc:		4 Wheel or All Wheel Drive			Driver's Side Air Bag
(Check All That Apply)		Passenger Air Bag			Side Curtain Air Bags
		Auto-Retract Seat Belts			Anti-Lock Brakes
		Anti-Theft System			Lo-Jack or On-Star
Comprehensive Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Collision Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Towing?		Yes			No
Rental?		Yes			No
Vehicle Usage (One Way Miles):		Pleasure			Drive to Work Under 3 Miles
		Drive to Work Under 10 Miles			Drive to Work Over 10 Miles
		Business Use			Artisan/Contractor
VEHICLE #2:
Vehicle Manufacturer:
Vehicle Model ( Include Model # ):
Vehicle Year:
Vehicle Type:		2 Door Automobile or SUV			4 Door Automobile or SUV
		2 Door Truck w/Standard Cab			2 Door Truck w/Extd Cab
		3 Door Truck			4 Door Truck/Quad Cab
Vehicle V.I.N. Number:
How many miles are on this vehicle?
How many miles is this vehicle driven per year?
Vehicle Options, Safety Equipment, Etc:		4 Wheel or All Wheel Drive			Driver's Side Air Bag
(Check All That Apply)		Passenger Air Bag			Side Curtain Air Bags
		Auto-Retract Seat Belts			Anti-Lock Brakes
		Anti-Theft System			Lo-Jack or On-Star
Comprehensive Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Collision Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Towing?		Yes			No
Rental?		Yes			No
Vehicle Usage (One Way Miles):		Pleasure			Drive to Work Under 3 Miles
		Drive to Work Under 10 Miles			Drive to Work Over 10 Miles
		Business Use			Artisan/Contractor
VEHICLE #3:
Vehicle Manufacturer:
Vehicle Model ( Include Model # ):
Vehicle Year:
Vehicle Type:		2 Door Automobile or SUV			4 Door Automobile or SUV
		2 Door Truck w/Standard Cab			2 Door Truck w/Extd Cab
		3 Door Truck			4 Door Truck/Quad Cab
Vehicle V.I.N. Number:
How many miles are on this vehicle?
How many miles is this vehicle driven per year?
Vehicle Options, Safety Equipment, Etc:		4 Wheel or All Wheel Drive			Driver's Side Air Bag
(Check All That Apply)		Passenger Air Bag			Side Curtain Air Bags
		Auto-Retract Seat Belts			Anti-Lock Brakes
		Anti-Theft System			Lo-Jack or On-Star
Comprehensive Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Collision Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Towing?		Yes			No
Rental?		Yes			No
Vehicle Usage (One Way Miles):		Pleasure			Drive to Work Under 3 Miles
		Drive to Work Under 10 Miles			Drive to Work Over 10 Miles
		Business Use			Artisan/Contractor
VEHICLE #4:
Vehicle Manufacturer:
Vehicle Model ( Include Model # ):
Vehicle Year:
Vehicle Type:		2 Door Automobile or SUV			4 Door Automobile or SUV
		2 Door Truck w/Standard Cab			2 Door Truck w/Extd Cab
		3 Door Truck			4 Door Truck/Quad Cab
Vehicle V.I.N. Number:
How many miles are on this vehicle?
How many miles is this vehicle driven per year?
Vehicle Options, Safety Equipment, Etc:		4 Wheel or All Wheel Drive			Driver's Side Air Bag
(Check All That Apply)		Passenger Air Bag			Side Curtain Air Bags
		Auto-Retract Seat Belts			Anti-Lock Brakes
		Anti-Theft System			Lo-Jack or On-Star
Comprehensive Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Collision Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Towing?		Yes			No
Rental?		Yes			No
Vehicle Usage (One Way Miles):		Pleasure			Drive to Work Under 3 Miles
		Drive to Work Under 10 Miles			Drive to Work Over 10 Miles
		Business Use			Artisan/Contractor
VEHICLE #5:
Vehicle Manufacturer:
Vehicle Model ( Include Model # ):
Vehicle Year:
Vehicle Type:		2 Door Automobile or SUV			4 Door Automobile or SUV
		2 Door Truck w/Standard Cab			2 Door Truck w/Extd Cab
		3 Door Truck			4 Door Truck/Quad Cab
Vehicle V.I.N. Number:
How many miles are on this vehicle?
How many miles is this vehicle driven per year?
Vehicle Options, Safety Equipment, Etc:		4 Wheel or All Wheel Drive			Driver's Side Air Bag
(Check All That Apply)		Passenger Air Bag			Side Curtain Air Bags
		Auto-Retract Seat Belts			Anti-Lock Brakes
		Anti-Theft System			Lo-Jack or On-Star
Comprehensive Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Collision Deductible:		No Coverage Desired			$100 Deductible
		$250 Deductible			$500 Deductible
		$750 Deductible			$1,000 Deductible
Towing?		Yes			No
Rental?		Yes			No
Vehicle Usage (One Way Miles):		Pleasure			Drive to Work Under 3 Miles
		Drive to Work Under 10 Miles			Drive to Work Over 10 Miles
		Business Use			Artisan/Contractor
DRIVER INFORMATION:
Driver Name:	Date of Birth	Sex	Marital Status	Driver's Ed	Good Student	Vehicle Driven
		M F	Single			Vehicle #1
			Married			Vehicle #2
			Divorced			Vehicle #3
			Separated			Vehicle #4
						Vehicle #5
		M F	Single			Vehicle #1
			Married			Vehicle #2
			Divorced			Vehicle #3
			Separated			Vehicle #4
						Vehicle #5
		M F	Single			Vehicle #1
			Married			Vehicle #2
			Divorced			Vehicle #3
			Separated			Vehicle #4
						Vehicle #5
		M F	Single			Vehicle #1
			Married			Vehicle #2
			Divorced			Vehicle #3
			Separated			Vehicle #4
						Vehicle #5
		M F	Single			Vehicle #1
			Married			Vehicle #2
			Divorced			Vehicle #3
			Separated			Vehicle #4
						Vehicle #5
Are there any other licensed drivers living in the house not covered under another policy?  If so, please indicate such and list their name, DOB, & Sex.
Do any drivers under this policy or any other policy in the house have any tickets, DWI's, at-fault accidents, or non-at fault accidents within the past 5 years?  If so, please list the driver and what happened.
Contact's Phone Number (Include Area Code):
Contact's Fax Number (Include Area Code):
Contact's E-Mail Address: