AUTO QUOTE

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Select State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming *

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/ / * What is your Birth Date (mm/dd/yyyy)

* Your Driver's License Number

* Your Social Security Number

* Your Occupation Place of Employment

Is this insurance quote for an Auto Motorcycle Boat Motor Home/Travel Trailer RV

Are you currently insured? Yes No

If YES, when does your current policy expire?

If YES, who are you currently insured with?

Have you taken a driver safety course? Yes No

Any Accidents? No Not At Fault Accident At Fault Accident

How long since last accident? Less than one year Between one and two years ago Between two and three years ago More than three years ago

Any Moving Violations? Never 1 2 3 4 5 or more

Does the vehicle have an alarm? No Active (Driver-Activated Ignition Disabling) Passive (Automatic Ignition Disabling) Alarm Only (No Ignition Disabling) Lojack (Vehicle Recovery System)

What is the primary use? Pleasure Commute Business (Corporate) Business (Individual) Government Competition

What is your Marital Status? Married Single Widowed Divorced Separated

Rate your own credit Excellent Minor problems Average Bad Horrible

Vehicle Make Vehicle Model

Year Built VIN #

(If Motorcycle, Boat, Motor Home/Travel Trailer or RV) What is the Horsepower?

(If Motorcycle, Boat, Motor Home/Travel Trailer or RV) What is the CC's

(If Motorcycle, Boat, Motor Home/Travel Trailer or RV) What is the value/cost.

How many miles a year do you drive? Less than 5000 5000 - 10000 10000 - 20000 20000 - 30000 30000 - 40000 30000 - 40000 40000 - 50000 More than 50000

Do you own a home? Yes No

If Auto, is your car equipped with antilock brakes? No All-Wheel Anti-Lock Rear-Wheel Only Front-Wheel Only Not Sure

If Auto, is your car equipped with airbags? No Driver's and Passenger's Side Only Driver's Side Only Passenger's Side Only Driver's, Passenger's and Side Impact

If Motorcycle, are you a member of any of these associations? No American Motorcyclist Association BMW Motorcycle Owners of America Harley Owners Group Honda Riders Club of America Retreads

If RV, are you a member of any of these associations? No AAA-Plus Campers Club of America Camping World President's Club Escapees Flying J Family Motor Coach Association Good Sams Club Manufacturers Club RPI Thousand Tails

If Boat, select type Runabout Cabin Cruiser Bass Boat Other Type of Fishing Boat Pontoon Boat House Boat Catamaran Sail Boat Mini Jet / Jet Boat Personal Watercraft: Jet Ski, WaveRunner Canoe, Kayak, Rowboat, Shuttlecraft Dinghy Multi Hull (other than catamaran) Amphibious Land Watercraft Airboat Other

.

Additional Drivers? Include in Quote Don't Include

Number of Drivers

Name of Additional Driver

/ / Birth Date (mm/dd/yyyy)

Any Accidents? No Not At Fault Accident At Fault Accident Any Moving Violations? Never 1 2 3 4 5 or more

Name of Additional Driver

/ / Birth Date (mm/dd/yyyy)

Any Accidents? No Not At Fault Accident At Fault Accident Any Moving Violations? Never 1 2 3 4 5 or more

Name of Additional Driver

/ / Birth Date (mm/dd/yyyy)

Any Accidents? No Not At Fault Accident At Fault Accident Any Moving Violations? Never 1 2 3 4 5 or more

Additional Vehicles? Include in Quote Don't Include

Vehicle Make Vehicle Model

Year Built VIN #

How many miles a year do you drive? Less than 5000 5000 - 10000 10000 - 20000 20000 - 30000 30000 - 40000 30000 - 40000 40000 - 50000 More than 50000

Does the vehicle have an alarm? No Active (Driver-Activated Ignition Disabling) Passive (Automatic Ignition Disabling) Alarm Only (No Ignition Disabling) Lojack (Vehicle Recovery System)

What is the primary use? Pleasure Commute Business (Corporate) Business (Individual) Government Competition

If Auto, is your car equipped with antilock brakes? No All-Wheel Anti-Lock Rear-Wheel Only Front-Wheel Only Not Sure

If Auto, is your car equipped with airbags? No Driver's and Passenger's Side Only Driver's Side Only Passenger's Side Only Driver's, Passenger's and Side Impact

Vehicle Make Vehicle Model

Year Built VIN #

How many miles a year do you drive? Less than 5000 5000 - 10000 10000 - 20000 20000 - 30000 30000 - 40000 30000 - 40000 40000 - 50000 More than 50000

Does the vehicle have an alarm? No Active (Driver-Activated Ignition Disabling) Passive (Automatic Ignition Disabling) Alarm Only (No Ignition Disabling) Lojack (Vehicle Recovery System)

What is the primary use? Pleasure Commute Business (Corporate) Business (Individual) Government Competition

If Auto, is your car equipped with antilock brakes? No All-Wheel Anti-Lock Rear-Wheel Only Front-Wheel Only Not Sure

If Auto, is your car equipped with airbags? No Driver's and Passenger's Side Only Driver's Side Only Passenger's Side Only Driver's, Passenger's and Side Impact

.

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