Auto Quote Name of Applicant Zip Code Phone Email Drivers Information - please list the following for each driver on the policy. Driver 1 First Name Last Name Date of Birth Marital Status Married Single Drivers License Any tickets or accidents in the last three years Any drivers qualify for good student? (3.0 GPA or higher, if enrolled in college has to be 12 units or more) Driver 2 First Name Last Name Date of Birth Marital Status Married Single Drivers License Any tickets or accidents in the last three years Any drivers qualify for good student? (3.0 GPA or higher, if enrolled in college has to be 12 units or more) Driver 3 First Name Last Name Date of Birth Marital Status Married Single Drivers License Any tickets or accidents in the last three years Any drivers qualify for good student? (3.0 GPA or higher, if enrolled in college has to be 12 units or more) Vehicles information - Please list the following for all the vehicles on the policy. Vehicle 1 Vin # Year Make Model Usage Work School Business Pleasuer Artisan Miles One Way Annual Miles Vehicle 2 Vin # Year Make Model Usage Work School Business Pleasuer Artisan Miles One Way Annual Miles Vehicle 3 Vin # Year Make Model Usage Work School Business Pleasuer Artisan Miles One Way Annual Miles Coverage Desired Bodily Injury Liability 15,000 per person 30,000 per accident 25,000 per person 50,000 per accident 50,000 per person 100,000 per accident 100,000 per person 300,000 per accident 250,000 per person 500,000 per accident 300,000 per person 300,000 per accident Property Damage Liability 10,000 per occurrence 15,000 per occurrence 25,000 per occurrence 50,000 per occurrence 100,000 per occurrence 250,000 per occurrence 300,000 per occurrence Uninsured Motorist Bodily Injury 15,000 per person 30,000 per accident 25,000 per person 50,000 per accident 30,000 per person 60,000 per accident 50,000 per person 100,000 per accident 100,000 per person 300,000 per accident 250,000 per person 500,000 per accident Uninsured Motorist Property Damge ($3,750 MAX) Yes No Medical Expenses 500 1,000 2,000 5,000 Comprehensive Deductible 25 50 100 200 250 500 1,000 2,000 Collision Deductible 100 250 500 1,000 2,000 Rental Car $30 per day for 30 days $40 per day for 30 days $50 per day for 30 days Comments Send
