Personal Lines Department
Automobile
We offer auto insurance to the full spectrum of drivers. We can place unlucky drivers in a number of companies and issue an immediate SR-22, or place a driver with a perfect record in one of our preferred carriers. Complete the attached brief profile and FAX back to us. We will also give you a more accurate phone quote by calling our toll free phone number. We will quote you with several carriers and offer you the best possible quotation.
	Name: First ________________________  Last____________________________________ Address: Street ___________________ City ______________ State ____ Zip Code _______ Daytime Phone (____) ______-_________ Ext _____ Fax Phone (_____) _______-________ Best Time to Call _______________   Drivers:                        Applicant           Driver 2               Driver 3                Driver 4 Full Name               _____________  _____________    _____________    _____________   Date of Birth          ____/___/____      ____/___/____      ____/___/____     ____/___/____ Sex                              M F                  M F                 M F                 M F Marital Status                M S                  M S                 M S                 M S Driver’s License #   _____________    ____________    _____________    ____________ # Years Licensed    _____________   ____________    _____________     ____________ # Years Prior Insurance __________  ____________    _____________     ____________   # Violations            _____________   ____________     _____________    ____________  # Accidents            _____________   ____________     _____________    ____________ Young Drivers: Good Student (full time) Yes No              Yes No                 Yes No                  Yes No Driver Training                Yes No            Yes No                 Yes No                  Yes No   Automobiles:           Auto 1                 Auto 2                     Auto 3                     Auto 4 Year/Make      ______________    ______________    ______________    _______________ Model/# doors _____________     ______________    ______________    _______________  # of Cylinders ______________     ______________    ______________    _______________ Est. Annual Mileage  __________   ______________    ______________    _______________ Check Coverage Desired Bodily Injury Liability Property Damage Liability ___$15,000/$30,000 bodily injury, $5,000 property damage ___$25,000/$50,000 bodily injury, $10,000 property damage ___$50,000/$100,000 bodily injury, $25,000 property damage ___$100,000/$300,000 bodily injury, $50,000 property damage ___$250,000/$500,000 bodily injury, $100,000 property damage   Medical Payments                                             Uninsured Motorists ___$1,000                                                           ___$15,000/$30,000 ___$2,000                                                           ___$25,000/$50,000 ___$5,000                                                           ___$30,000/$60,000                                                                             ___$50,000/$100,000                                                                             ___$100,000/$300,000 Comprehensive and Collision Deductibles    Vehicle 1                        Vehicle 2                     Vehicle 3                    Vehicle 4 ___No Coverage           ___No Coverage          ___No Coverage         ___No Coverage  ___$250                        ___ $250                     ___$250                      ___$250 ___$500                        ___$500                      ___$500                      ___$500 ___$1,000                     ___$1,000                   ___$1,000                   ___$1,000     Homeowners   We offer coverage through many fine insurance companies. They include Safeco, Mercury, Chubb, Fireman's Fund, Five Star, and Farmers. Please complete and fax the form below, or call for a free telephone quote. Amount of coverage__________________ Year built_________ Square footage___________ Present insurance company________________________ Expiration date________________ Deductible desired___________________ Do you wish Earthquake coverage_____________ List all claims reported in the past five years________________________________________ _________________________________________________________________________ For coverage on high valued or scheduled items, please call our office.