Agent Information
Agent Name:
Phone:	Fax:
Email Address:

 

Required*   Applicant acknowledges that a MVR/CLUE Report MVR Report Motor Vehicle Report: Your driving record (obtained from the state department of motor vehicles) helps determine how to set your rate, showing information about your driver license, traffic violations, and sometimes personal information. CLUE Report Comprehensive Loss Underwriting Exchange: Underwriters use the information in a CLUE report to rate insurance policies. An automobile CLUE loss history report provides insurance company names and policy numbers and any claim numbers. The report lists the dates of any claims, the loss types and amounts paid for losses, and it will tell if a claim was denied. may be obtained during the quoting process

 

Personal Information
Name:
Address:
City:	State:   Zip:
Years at this Address:
Phone:
Email Address:

 

Current Auto Insurance Information
Company Name (not agency):
How long with this company/carrier?:
Policy Expiration Date:	Premium Amount: $
Term:	6 Months   1 Year   Other:

 

Vehicle Information
(include all cars you or your family members own or lease)
Car #1	Year	Make	Model	Year Purchased	Body Type	Vehicle ID# (VIN)
Odometer		Annual Mileage	Drive to school/work?		# of miles (one way)	Airbags	Car Alarm
			Y N			Y   N	Y   N
If vehicle is kept at an address other than that listed above, please indicate below
Location City:   State:   Zip:
Comprehensive Deductible			Collision Deductible			Towing	Loss of Use
$100 $250 $500			$250 $500 $1000			Y   N	Y   N

 

Liability Limit For ALL Cars
Choose either   Bodily Injury, Medical Payment, and Property Damage	or   Single Limit
Bodily Injury $25,000/50,000 $50,000/100,000 $100,000/300,000 $250,000/500,000          Medical Payment $1,000 $2,000 $5,000 $10,000          Property Damage $25,000 $50,000 $100,000 $500,000	Single Limit $60,000 $100,000 $300,000 $500,000

 

Driver Information (include all licensed drivers in your household)
Driver #1	Driver's Name	Occupation	Drivers License Information
			DL#: State: Yr's Licensed:
Relation	Date of Birth	Sex	Marital Status	4Yr College Degree	Driver's Education	Accident Prevention
		M F	M S	Y N	Y N	Y N
List ANY convictions for moving traffic violations (tickets) in the past 3 years
Date		Type of Conviction			Fines	Speed Over Limit
					$	mph
					$	mph
List ANY DUI convictions, license suspensions, or revocations in the past 7 years
DUI Conviction For Alcohol:		DUI Conviction For Drugs:		License Suspended		License Revoked
Y   N		Y   N		Y   N		Y   N
List ANY accidents, regardless of fault, in the past 5 years
Date	Description	Injuries	At Fault		Cost	Fines
		Y  N	Y  N		$	$
		Y  N	Y  N		$	$

 

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

 

Form Submission

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