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Name
*
Address
*
Phone Number
*
Email
*
How did you hear about us?
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Commercial
Newspaper/magazine
Mailer
Online Search
Current Customer
Referred by
Referred by
Drivers :
Driver
1
Name
*
Birthday
*
Driver’s license number
Married
Single
Divorced
Widowed
Any accidents or violations in the last 5 years (date and activity)
-
+
Vehicles:
Vehicle:
1
Year
Make
Model
VIN
Titled to
Usage
Select
business
pleasure
commute to work/school
Miles one way
Employer/School
This vehicle is used to rideshare (uber, lyft)
Yes
No
-
+
Current Insurance Carrier
Current Coverage Policy Level:
Tort
Limited
Full
Bodily Injury
Select
15,000/30,000
20,000/40,000
25,000/50,000
50,000/100,000
100,000/100,000
100,000/300,000
250,000/500,000
300,000/300,000
300,000/500,000
500,000/500,000
500,000/1,000,000
1,000,000/1,000,000
Property Damage
Select
5,000
10,000
25,000
50,000
100,000
200,000
250,000
300,000
500,000
1,000,000
Medical Expense
None
5,000
10,000
25,000
50,000
100,000
Income Loss
Select
1,000 per month/5,000 Max
1,000 per month/ 15,000 Max
1,500 per month/25,000 Max
2,500 per month/50,000 Max
5,000 per month/100,000 Max
Accidental Death
Select
5,000
10,000
25,000
Funeral Benefit
Select
1500
2500
Extraordinary Medical Benefit
Yes
No
Uninsured Motorist
Select
Stacked
Unstacked
Select
15,000/30,000
20,000/40,000
25,000/50,000
50,000/100,000
100,000/100,000
100,000/300,000
250,000/500,000
300,000/300,000
300,000/500,000
500,000/500,000
500,000/1,000,000
1,000,000/1,000,000
Underinsured Motorist
Select
Stacked
Unstacked
Select
15,000/30,000
20,000/40,000
25,000/50,000
50,000/100,000
100,000/100,000
100,000/300,000
250,000/500,000
300,000/300,000
300,000/500,000
500,000/500,000
500,000/1,000,000
1,000,000/1,000,000
Current Coverages by car:
Comprehensive
Select
50 Deductible
100 Deductible
150 Deductible
200 Deductible
250 Deductible
500 Deductible
1,000 Deductible
1,500 Deductible
2,000 Deductible
2,500 Deductible
5,000 Deductible
10,000 Deductible
Collision
Select
100 Deductible
150 Deductible
200 Deductible
250 Deductible
500 Deductible
1,000 Deductible
1,500 Deductible
2,000 Deductible
2,500 Deductible
5,000 Deductible
10,000 Deductible
Road Service
Yes
No
Rental Car
Select
20/day
25/day
30/day
35/day
40/day
Gap Insurance
Yes
No
Diminishing Deductible
Yes
No
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