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AUTO / CAR INSURANCE FORM

* = required
Name:*
Phone Number:*(xxx-xxx-xxxx)
Email Address:*
Address:
 
City:
State:
Zip:
Date of Birth:(mm/dd/yyyy)
How Many Cars:
How Many Drivers:
Do You Currently Have Insurance: yes no
How Long Without A Gap More Or Less Than 60 Days:
How Long Without A Gap More Or Less Than 30 Days:
Year Of Car:(yyyy)
Make:
Model:
Body Type: sedan coupe convertible SUV / Truck
Anti-Theft Devices: yes no
Used For Business Other Than Driving To And From Work: yes no
If Yes, How Many Miles Per Driven For Business: business miles
Estimated Annual Mileage: annual miles
Are You A Fulltime Student: yes no
Marital Status: married single
Gender: male female
Age First Licensed: years old
Employment Status: employeed unemployeed
Accidents In Last 5 Years: yes no
Violations In Last 5 Years: yes no
Theft/Vandalism In Last 5 Years: yes no
Suspensions In Last 5 Years: yes no
Bodily Injury Liability: $20,000/$40,000 $25,000/$50,000 $50,000/$100,000 $100,000/$200,000 $100,000/$300,000 $300,000/$300,000 $250,000/$500,000
Property Damage Liability: $50,000 $20,000 $25,000 $50,000 $100,000
Medical Payments: I Decline $1,000 $2,000 $5,000 $7,500 $10,000 $15,000 $25,000
Uninsured Motorist Bodily Injury: $20,000/$40,000 $25,000/$50,000 $50,000/$100,000 $100,000/$200,000 $100,000/$300,000 $300,000/$300,000 $250,000/$500,000
Underinsured Motorist: $20,000/$40,000 $25,000/$50,000 $50,000/$100,000 $100,000/$200,000 $100,000/$300,000 $300,000/$300,000 $250,000/$500,000
Uninsured Motorist
Property Damage:		 $15,000 I decline this coverage
Comprehensive: I decline this coverage $1,000 deductible $500 deductible $250 deductible $200 deductible $100 deductible $50 deductible No deductible
Collision: I decline this coverage $1,000 deductible $500 deductible $250 deductible $200 deductible $100 deductible $50 deductible
Emergency Road Service: I accept this coverage I decline this coverage
Rental Reimbursement: I decline this coverage $25/day, $750 max per claim
$50/day, $1,500 max per claim
 
 
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