Social Security
#
DRIVER
#2
Driver #2 Drives Marital Status Usage
Car #1
Car #2
Car #3
Car #4
Married
Single
Pleasure
Work <15 miles
Work >15 miles
Business Use
Driver #2 Occupation Birthdate
Male
Female
N/A
3.0 or above
Below 3.0
Tell
us about the last 3 years. During that time...
1) How
many citations have you had?
None
1
2
3
4
5
6
Over 6
2)
How many "at fault" accidents have you
had?
None
1
2
3
4
5
6
Over 6
3)
How many "not at fault" accidents have
you had?
None
1
2
3
4
5
6
Over 6
4)
How many comprehensive (glass breakage, theft,
vandalism) claims have you had?
None
1
2
3
4
5
6
Over 6
DRIVER
#3
Driver #3 Drives Marital Status Usage
Car #1
Car #2
Car #3
Car #4
Married
Single
Pleasure
Work <15 miles
Work >15 miles
Business Use
Driver #3 Occupation Birthdate
Male
Female
N/A
3.0 or above
Below 3.0
Tell
us about the last 3 years. During that time...
1) How
many citations have you had?
None
1
2
3
4
5
6
Over 6
2)
How many "at fault" accidents have you
had?
None
1
2
3
4
5
6
Over 6
3)
How many "not at fault" accidents have
you had?
None
1
2
3
4
5
6
Over 6
4)
How many comprehensive (glass breakage, theft,
vandalism) claims have you had?
None
1
2
3
4
5
6
Over 6
DRIVER
#4
Driver #4 Drives Marital Status Usage
Car #1
Car #2
Car #3
Car #4
Married
Single
Pleasure
Work <15 miles
Work >15 miles
Business Use
Driver #4 Occupation Birthdate
Male
Female
N/A
3.0 or above
Below 3.0
Tell
us about the last 3 years. During that time...
1) How
many citations have you had?
None
1
2
3
4
5
6
Over 6
2)
How many "at fault" accidents have you
had?
None
1
2
3
4
5
6
Over 6
3)
How many "not at fault" accidents have
you had?
None
1
2
3
4
5
6
Over 6
4)
How many comprehensive (glass breakage, theft,
vandalism) claims have you had?
None
1
2
3
4
5
6
Over 6
POLICY QUESTIONS
For
how long have you been continuously insured without
a lapse?
Less than 6 months
6 - 11 months
12 - 23 months
24 or more months
What were the
lowest Bodily Injury limits on your policy in the past 6
months? (Please choose one).
State Minimum Limits
Greater Than State Minimum - Less Than 50/100
Greater Than or Equal to 50/100, Less Than
100/300 or 100CSL
Equal To or Greater Than 100/300 or 100 CSL
Present
Insurance Company:
Do you have any
questions or comments for us?
SEND MY QUOTE
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Phone
Fax
Postal Mail
