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Your Information
Last Name
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First Name
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Email Address
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Street Address
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City
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State
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Zip Code
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Phone Number
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Alternate Phone
Birth Date (DD/MM/YYYY)
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Are any aircraft owned, leased, chartered or furnished for regular use?
Yes
No
Do any drivers have mental or physical impairments?
Yes
No
Are any premises, vehicles, watercraft, aircraft used for business?
Yes
No
Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies?
Yes
No
Do you hold any non-remunerative positions?
Yes
No
Any non-owned property exceeding $1,000 in value in your care, custody or control?
Yes
No
Any non-owned business or professional activities included in the primary policies?
Yes
No
Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?
Yes
No
Was any coverage declined, cancelled or non-renewed within the past 5 years?
Yes
No
Any motorcycles, mopeds or all terrain vehicles owned?
Yes
No
Any other business activities conducted from your residence or premises?
Yes
No
Please explain any YES answers from above
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Drivers Information
Driver 1 Information
First Name
Last Name
Date of Birth (DD/MM/YYYY)
...
Gender
Male
Female
Marital Status
Single
Married
Separated
Divorced
Widowed
Domestic Partner
Years Licensed
State Licensed
Occupation
Violation Information
Last 3 years (minor violations) / Last 5 years (major violations)
Minor Violations - speeding, turn, stop sign, red light, etc.
None
1
2
3
4
Accidents - non chargeable
None
1
2
3
4
Accidents - chargeable
None
1
2
3
4
Major violations - DUI, DWI, reckless,hit and run, etc.
None
1
2
3
4
Driver 2 Information
First Name
Last Name
Date of Birth (DD/MM/YYYY)
...
Gender
Male
Female
Marital Status
Single
Married
Separated
Divorced
Widowed
Domestic Partner
Years Licensed
State Licensed
Occupation
Violation Information
Last 3 years (minor violations) / Last 5 years (major violations)
Minor Violations - speeding, turn, stop sign, red light, etc.
None
1
2
3
4
Accidents - non chargeable
None
1
2
3
4
Accidents - chargeable
None
1
2
3
4
Major violations - DUI, DWI, reckless,hit and run, etc.
None
1
2
3
4
Driver 3 Information
First Name
Last Name
Date of Birth (DD/MM/YYYY)
...
Gender
Male
Female
Marital Status
Single
Married
Separated
Divorced
Widowed
Domestic Partner
Years Licensed
State Licensed
Occupation
Violation Information
Last 3 years (minor violations) / Last 5 years (major violations)
Minor Violations - speeding, turn, stop sign, red light, etc.
None
1
2
3
4
Accidents - non chargeable
None
1
2
3
4
Accidents - chargeable
None
1
2
3
4
Major violations - DUI, DWI, reckless,hit and run, etc.
None
1
2
3
4
Driver 4 Information
First Name
Last Name
Date of Birth (DD/MM/YYYY)
...
Gender
Male
Female
Marital Status
Single
Married
Separated
Divorced
Widowed
Domestic Partner
Years Licensed
State Licensed
Occupation
Violation Information
Last 3 years (minor violations) / Last 5 years (major violations)
Minor Violations - speeding, turn, stop sign, red light, etc.
None
1
2
3
4
Accidents - non chargeable
None
1
2
3
4
Accidents - chargeable
None
1
2
3
4
Major violations - DUI, DWI, reckless,hit and run, etc.
None
1
2
3
4
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Vehicle Information
Vehicle 1 Information
Year
Make
Model
Vin #
Miles per Year
Where Parked at Night
Airbag (drivers)
Yes
No
Airbag (driver & passenger)
Yes
No
Side Airbags (driver & passenger)
Yes
No
Anti-Theft Device
Yes
No
Smart Technology
Yes
No
Ownership
Deductible Information
Comp (theft)
None
$250
$500
$1000
$1500
$2000
Collision
None
$250
$500
$1000
$1500
$2000
Vehicle 2 Information
Year
Make
Model
Vin #
Miles per Year
Where Parked at Night
Airbag (drivers)
Yes
No
Airbag (driver & passenger)
Yes
No
Side Airbags (driver & passenger)
Yes
No
Anti-Theft Device
Yes
No
Smart Technology
Yes
No
Ownership
Deductible Information
Comp (theft)
None
$250
$500
$1000
$1500
$2000
Collision
None
$250
$500
$1000
$1500
$2000
Vehicle 3 Information
Year
Make
Model
Vin #
Miles per Year
Where Parked at Night
Airbag (drivers)
Yes
No
Airbag (driver & passenger)
Yes
No
Side Airbags (driver & passenger)
Yes
No
Anti-Theft Device
Yes
No
Smart Technology
Yes
No
Ownership
Deductible Information
Comp (theft)
None
$250
$500
$1000
$1500
$2000
Collision
None
$250
$500
$1000
$1500
$2000
Vehicle 4 Information
Year
Make
Model
Vin #
Miles per Year
Where Parked at Night
Airbag (drivers)
Yes
No
Airbag (driver & passenger)
Yes
No
Side Airbags (driver & passenger)
Yes
No
Anti-Theft Device
Yes
No
Smart Technology
Yes
No
Ownership
Deductible Information
Comp (theft)
None
$250
$500
$1000
$1500
$2000
Collision
None
$250
$500
$1000
$1500
$2000
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Thank you for your Auto Insurance quote. One of our advisers will contact you soon.
Miscellaneous and Claims Information
What is the number of single family dwellings you own?
What is the number of autos you own?
What is the number of recreational vehicles you own?
What is the number of multi-unit buildings you own?
What is the number of vacant property (land) you own?
What is the number of motorcycles you own?
Were there any losses or claims in the last 5 years?
Yes
No
If yes, what is the date, amount paid and description of each loss or claim?
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Coverage Information
Personal Liability / Bodily Injury
$15,000/30,000
$25,000/50,000
$30,000/60,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
Personal Liability / Property Damage
$5,000
$10,000
$25,000
$50,000
$100,000
Uninsured Motorist / Bodily Injury
No Coverage
$15,000/30,000
$25,000/50,000
$30,000/60,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
Uninsured Motorist / Property Damage
No Coverage
$3500
Deductible Waiver
Medical Payment
None
$1000
$2000
$2500
$5000
$10,000
$15,000
$20,000
$25,000
$50,000
$100,000
Miscellaneous Information
Current Insurance Company
Expiration Date (DD/MM/YYYY)
...
Current Premium
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Intro to Recreational Vehicle Ins
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