Tell us the
current coverages on your cars?
Comprehensive Deductible |
|
Collision Deductible |
|
Bodily Injury Liability
Limit
(000) |
|
Property Damage Liability
Limit |
|
Uninsured
Motorist Bodily
Injury Liability (000) |
|
Uninsured Motorist Property
Damage Liability |
|
Personal Injury Protection |
|
Medical Payments |
|
Road Service Coverage |
|
Rental Car
Reimbursement |
|
What month current policy
expire? |
|
What is the
name current
insurance company? |
|
Accidents &
Violations
|
Last 3 Yrs (Minors)
Last 5 Yrs
(Majors) |
Driver
1 |
Driver
2 |
Driver
3 |
Driver
4 |
Minor Violations - Speeding, Illegal Turn,
Stop Sign, Red Light, etc. (Within the last 3 years) |
|
|
|
|
Accidents - Non Chargeable (Within the
last 5 years) |
|
|
|
|
Accidents
- Chargeable (Within the last
5 years) |
|
|
|
|
Major Violations - Drunk
Driving, Reckless,
Hit & Run, Speeding - Greater than 30 MPH
over limit (Within
the last 5 years) |
|
|
|
|