How Many Vehicles Do You Have? * 1 2 3 4 5 6 7
Year / Make / Model - Vehicle 1
VIN - Vehicle 1 *
Vehicle 1 Use * Pleasure Commute Work/School Business
Commute Work Daily Mileage One Way - Vehicle 1 0 - 3 Miles 4 - 10 Miles 11 - 19 Miles 20+ Miles
Rental - Vehicle 1 Yes No
Comprehensive Deductible - Vehicle 1 * No Coverage $250 $500 $1,000
Collision Deductible - Vehicle 1 * No Coverage $250 $500 $1,000
Length of Ownership - Vehicle 1 Less Than 1 Month Greater Than 1 Month but Less Than a Year More Than 1 Year but Less Than 3 Years 3 - 4 Years 5+ Years
Year / Make / Model - Vehicle 2
VIN - Vehicle 2 *
Vehicle 2 Use Pleasure Commute Work/School Business
Commute Work Daily Mileage One Way - Vehicle 2 0 - 3 Miles 4 - 10 Miles 11 - 19 Miles 20+ Miles
Rental - Vehicle 2 Yes No
Comprehensive Deductible - Vehicle 2 No Coverage $250 $500 $1,000
Collision Deductible - Vehicle 2 No Coverage $250 $500 $1,000
Length of Ownership - Vehicle 2 Less Than 1 Month Greater Than 1 Month but Less Than a Year More Than 1 Year but Less Than 3 Years 3 - 4 Years 5+ Years
Year / Make / Model - Vehicle 3
VIN - Vehicle 3 *
Vehicle 3 Use Pleasure Commute Work/School Business
Commute Work Daily Mileage One Way - Vehicle 3
Rental - Vehicle 3 Yes No
Comprehensive Deductible - Vehicle 3 No Coverage $250 $500 $1,000
Collision Deductible - Vehicle 3 No Coverage $250 $500 $1,000
Length of Ownership - Vehicle 3 Less Than 1 Month Greater Than 1 Month but Less Than a Year More Than 1 Year but Less Than 3 Years 3 - 4 Years 5+ Years
Year / Make / Model - Vehicle 4
VIN - Vehicle 4 *
Vehicle 4 Use Pleasure Commute Work/School Business
Commute Work Daily Mileage One Way - Vehicle 4 0 - 3 Miles 4 - 10 Miles 11 - 19 Miles 20+
Rental - Vehicle 4 Yes No
Comprehensive Deductible - Vehicle 4 No Coverage $250 $500 $1,000
Collision Deductible - Vehicle 4 No Coverage $250 $500 $1,000
Length of Ownership - Vehicle 4 Less Than 1 Month Greater Than 1 Month but Less Than a Year More Than 1 Year but Less Than 3 Years 3 - 4 Years 5+ Years
Year / Make / Model - Vehicle 5
VIN - Vehicle 5 *
Vehicle 5 Use Pleasure Commute Work/School
Commute Work Daily Mileage One Way - Vehicle 5 0 - 3 Miles 4 - 10 Miles 11 - 19 Miles 20+ Miles
Rental - Vehicle 5 Yes No
Comprehensive Deductible - Vehicle 5 No Coverage $250 $500 $1,000
Collision Deductible - Vehicle 5 No Coverage $250 $500 $1,000
Length of Ownership - Vehicle 5 Less Than 1 Month Greater Than 1 Month but Less Than a Year More Than 1 Year but Less Than 3 Years 3 - 4 Years 5+ Years
Year / Make / Model - Vehicle 6
VIN - Vehicle 6 *
Vehicle 6 Use Pleasure Commute Work/School Business
Commute Work Daily Mileage One Way - Vehicle 6 0 - 3 Miles 4 - 10 Miles 11 - 19 Miles 20+ Miles
Rental - Vehicle 6 Yes No
Comprehensive Deductible - Vehicle 6 No Coverage $250 $500 $1,000
Collision Deductible - Vehicle 6 No Coverage $250 $500 $1,000
Length of Ownership - Vehicle 6 Less Than 1 Month Greater Than 1 Month but Less Than a Year More Than 1 Year but Less Than 3 Years 3 - 4 Years 5+ Years
Year / Make / Model - Vehicle 7
VIN - Vehicle 7 *
Vehicle 7 Use Pleasure Commute Work/School Business
Commute Work Daily Mileage One Way - Vehicle 7 0 -3 Miles 4 - 10 Miles 11 - 19 Miles 20 Miles
Rental - Vehicle 7 Yes No
Comprehensive Deductible - Vehicle 7 No Coverage $250 $500 $1,000
Collision Deductible - Vehicle 7 No Coverage $250 $500 $1,000
Length of Ownership - Vehicle 7 Less Than 1 Month Greater Than 1 Month but Less Than a Year More Than 1 Year but Less Than 3 Years 3 - 4 Years 5+ Years
Have any drivers had any accidents, violations, or claims in the last 5 years? If so, provide dates and a brief explanation.
Bodily Injury Liability * $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Property Damage Liability * $25,000 $50,000 $100,000 $250,000 $300,000
Personal Injury Protection * None $10,000 $20,000 $30,000 $40,000 $50,000
Uninsured Motorist - Bodily Injury Limits * None $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Underinsured Motorist - Bodily Injury Limits * None $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
