Part 1 - General Information Full Name: E-Mail Address: Street Address:    Apt# City: State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Day Time Phone: Part II - Vehicle Information Vehicle#1-  Year    Make Model (Include XL, XLT, etc.) Type of Vehicle: 2 Door  4 Door  Coupe  Sedan  Pickup  4X2  4X4  Convertible Passenger Restraint: Driver Side Only   Both Sides  Anti-Theft Device Yes No Annual Mileage Vehicle#2-  Year    Make Model (Include XL, XLT, etc.) Vin# Type of Vehicle: 2 Door  4 Door  Coupe  Sedan  Pickup  4X2  4X4  Convertible Passenger Restraint: Driver Side Only   Both Sides  Anti-Theft Device Yes No Annual Mileage Vehicle#3-  Year    Make Model (Include XL, XLT, etc.) Vin# Type of Vehicle: 2 Door  4 Door  Coupe  Sedan  Pickup  4X2  4X4  Convertible Passenger Restraint: Driver Side Only   Both Sides  Anti-Theft Device Yes No Annual Mileage Part III- Driver Information Driver #1- Date of Birth   License# (REQUIRED) Licensed State: (REQUIRED) Years Licensed:  Under 3 Years  3-6 years  Over 6 years Accidents at Fault Last 6 years: Moving Violations Last 6 years: Drivers Education Taken? Yes  No Driver #2- Date of Birth License# Licensed State: Years Licensed:  Under 3 Years  3-6 years  Over 6 years Accidents at Fault Last 6 years: Moving Violations Last 6 years: Drivers Education Taken? Yes  No Driver #3- Date of Birth License# Licensed State: Years Licensed:  Under 3 Years  3-6 years  Over 6 years Accidents at Fault Last 6 years: Moving Violations Last 6 years: Drivers Education Taken? Yes  No Part IV - Coverage Information Coverage's Vehicle #1 Vehicle #2 Vehicle #3 MANDATORY       Part 1: Bodily Injury 20,000/40,000 20,000/40,000 20,000/40,000 Part 2: Personal Injury Protection 8,000 8,000 8,000 Part 3: Uninsured Motorists 20,000/40,000 20,000/50,000 25,000/50,000 35,000/80,000 50,000/100,000 100,000/300,000 250,000/500,000-$ 500,000/1,000,000 20,000/40,000 20,000/50,000 25,000/50,000 35,000/80,000 50,000/100,000 100,000/300,000 250,000/500,000-$ 500,000/1,000,000 20,000/40,000 20,000/50,000 25,000/50,000 35,000/80,000 50,000/100,000 100,000/300,000 250,000/500,000-$ 500,000/1,000,000 Part 4: Property Damage SELECT ============== 5,000 10,000 25,000 50,000 100,000 SELECT ============== 5,000 10,000 25,000 50,000 100,000 SELECT ============== 5,000 10,000 25,000 50,000 100,000 OPTIONAL       Part 5: Optional Bodily Injury 100,000/300,000 20,000/40,000 25,000/50,000 50,000/100,000 250,000/500,000 500,000/500,000 500,000/1m 1m/1m No Coverage ============== OPTIONAL 100,000/300,000 20,000/40,000 25,000/50,000 50,000/100,000 250,000/500,000 500,000/500,000 500,000/1m 1m/1m No Coverage ============== OPTIONAL 100,000/300,000 20,000/40,000 25,000/50,000 50,000/100,000 250,000/500,000 500,000/500,000 500,000/1m 1m/1m No Coverage ============== OPTIONAL Part 6: Medical Payments 5,000 10,000 15,000 20,000 25,000 50,000 100,000 No Coverage ============== OPTIONAL 5,000 10,000 15,000 20,000 25,000 50,000 100,000 No Coverage ============== OPTIONAL 5,000 10,000 15,000 20,000 25,000 50,000 100,000 No Coverage ============== OPTIONAL Part 7: Collision Deductible 300 500 1,000 2,000 No Coverage OPTIONAL 300 500 1,000 2,000 No Coverage OPTIONAL 300 500 1,000 2,000 No Coverage OPTIONAL Part 8: Limited Collision 0 300 500 No Coverage OPTIONAL 0 300 500 No Coverage OPTIONAL 0 300 500 No Coverage OPTIONAL Part 9: Comprehensive Deduct. 300 500 1,000 2,000 No Coverage OPTIONAL 300 500 1,000 2,000 No Coverage OPTIONAL 300 500 1,000 2,000 No Coverage OPTIONAL Part 10: Substitute Transportation $15/day-$450 Max $30/day-$900 Max $100/day-$3,000 Max No Coverage OPTIONAL $15/day-$450 Max $30/day-$900 Max $100/day-$3,000 Max No Coverage OPTIONAL $15/day-$450 Max $30/day-$900 Max $100/day-$3,000 Max No Coverage OPTIONAL Part 11: Towing & Labor $25 per disablement $50 per disablement No Coverage OPTIONAL $25 per disablement $50 per disablement No Coverage OPTIONAL $25 per disablement $50 per disablement No Coverage OPTIONAL Part 12: Underinsured Motorists 100,000/300,000 20,000/40,000 25,000/50,000 50,000/100,000 250,000/500,000 500,000/500,000 500,000/1m 1m/1m No Coverage ============== OPTIONAL 100,000/300,000 20,000/40,000 25,000/50,000 50,000/100,000 250,000/500,000 500,000/500,000 500,000/1m 1m/1m No Coverage ============== OPTIONAL 100,000/300,000 20,000/40,000 25,000/50,000 50,000/100,000 250,000/500,000 500,000/500,000 500,000/1m 1m/1m No Coverage ============== OPTIONAL

  © 2001-2008 Choice Insurance Agency
Privacy Policy  |  Web Site by Blue Mountain Creative