AUTO INSURANCE QUOTE SHEET - AUTO INSURANCE QUOTE SHEET This is a request for a quotation for automobile
AUTO INSURANCE QUOTE SHEET - AUTO INSURANCE QUOTE SHEET This is a request for a quotation for automobile
AUTO INSURANCE QUOTE SHEET - AUTO INSURANCE QUOTE SHEET This is a request for a quotation for automobile

AUTO INSURANCE QUOTE SHEET - AUTO INSURANCE QUOTE SHEET This is a request for a quotation for automobile

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  • AUTO INSURANCE QUOTE SHEET

    This is a request for a quotation for automobile insurance. It is not an application for insurance. To expedite your quote, please provide the following information.

    Name: Address: City: State: Zip: Phone #: Best Time to Call: Morning Afternoon Evening Own Home: Rent Home: Live with Parents: Email address: Current Insurance Co.: Expiration Date:

    VEHICLE INFORMATION

    Year Make Model VIN # Vehicle Usage One-Way Commute Mileage Primary Driver of

    Vehicle

    1.

    2.

    3.

    4.

    5.

    Are all vehicles titled in insured’s and/or spouse’s name? Yes No

    If no, select which vehicle(s) are titled in a name other than the insured’s and/or spouse’s: 1 2 3 4 5 Titleholder(s):

    Are all of the vehicles kept at above address? Yes No If no, which vehicle(s) are kept elsewhere? 1 2 3 4 5 Address:

    Are any of the vehicles leased? Yes No

    If yes, which vehicle(s)? 1 2 3 4 5 Name & address of leasing company(s): Are any of the vehicles financed? Yes No

    If yes, which vehicle(s)? 1 2 3 4 5 Name & address of lienholder(s): Are any of the vehicles used for business? (hauling tools, delivery services, customer visitations, etc.) Yes No

    If yes, which vehicle(s)? 1 2 3 4 5 Type of business use:

  • DRIVERS IN HOUSEHOLD

    Name Birthdate Marital Status Relationship Occupation Education License #

    Date Licensed if Driving < 4

    Years

    SSN

    1.

    2.

    3.

    4.

    5.

    Has any driver (age 21 & under) completed a “Behind the Wheel” Training course within past 3 years? Yes No

    If yes, which driver(s)? 1 2 3 4 5 *Copy of course completion certificate is not needed for quoting purposes, but is required purchase policy

    Does any driver currently in school/college maintain an A/B average? Yes No If yes, which driver(s)? 1 2 3 4 5

    *Copy of most recent report card/transcript is not needed for quoting purposes, but is required purchase policy

    Is any driver attending a school/college 100+ miles away from home without a vehicle? Yes No If yes, which driver(s)? 1 2 3 4 5 Name & address of school:

    Has any driver (age 55 & older) completed the “55 & Alive” driver training course within the past 3 years? Yes No

    If yes, which driver(s)? 1 2 3 4 5

    DRIVING HISTORY (Past 5 years) Has any driver had his/her driver’s license suspended or revoked? Yes No If yes, please provide driver name, date of suspension/revocation, and reason for suspension/revocation:

    Has any driver had any accidents or violations? (list at-fault & not-at-fault accidents) Yes No If yes, please provide driver name, date of accident/violation and brief explanation of accident/violation:

    List all fire, theft, glass, vandalism and/or other Comprehensive Claims:

    Date: Type: Date: Type:

    COVERAGES Tort Option: Full Limited Bodily Injury Liability Limit: Property Damage:

  • Uninsured Motorist Limit: Rejected Stacked Non-Stacked Underinsured Motorist Limit: Rejected Stacked Non-Stacked Medical Expenses/PIP Limit: Extraordinary Med. Benefit: Yes No

    Work/Income Loss Limit:

    Accidental Death Benefit: Funeral Benefit:

    Comprehensive Coverage Collision Coverage Vehicle 1 Deductible: Vehicle 1 Deductible:

    Vehicle 2 Deductible: Vehicle 2 Deductible:

    Vehicle 3 Deductible: Vehicle 3 Deductible:

    Vehicle 4 Deductible: Vehicle 4 Deductible:

    Vehicle 5 Deductible: Vehicle 5 Deductible:

    Towing/Roadside Assistance Coverage Limit: Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5

    Rental Reimbursement /Transportation Expenses Coverage Limit: Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5

    Repair/Replacement Coverage *(Only available for new model year vehicles. Coverage must be on current policy OR vehicle(s) must have been purchased within past 30 days)* Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Loan/Lease Gap Coverage *(Only available for new model year vehicles. Coverage must be on current policy OR vehicle(s) must have been purchased within past 30 days)* Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Customized Equipment/Accessory Coverage

    Coverage Limit: Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 List of Custom Equipment/Accessories:

    Additional Information/Comments:

    As part of the underwriting process, insurance companies will order an insurance score based upon your credit history that will be used to underwrite and price your policy. As allowed by law, they may obtain credit and other consumer reports, such as claims

    history reports, in connection with your application for insurance and any renewal of insurance. Phone: 717-795-5245 or 800-283-2328, ext. 5245 * Email: Members1stInsuranceServices@members1st.org

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    bloodk Typewritten Text Date Completed: Completed By:

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    bloodk Typewritten Text Reject Towing/Roadside Coverage

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    bloodk Typewritten Text Reject Rental Reimbursement/Trans. Expenses Coverage

    bloodk Typewritten Text Reject Loan/Lease Coverage

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    bloodk Typewritten Text Reject Repair/Replace Coverage

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    bloodk Typewritten Text Rejected

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    bloodk Typewritten Text Rejected Work/Income Loss Coverage

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    Rent Home: Off Live with Parents: Off Morning: Off Afternoon: Off Evening: Off Model1: OneWay Commute Mileage1: Primary Driver of Vehicle1: Make2: Model2: VIN 2: OneWay Commute Mileage2: Primary Driver of Vehicle2: Make3: Model3: VIN 3: OneWay Commute Mileage3: Primary Driver of Vehicle3: Make4: Model4: VIN 4: OneWay Commute Mileage4: Primary Driver of Vehicle4: Make5: Model5: OneWay Commute Mileage5: Primary Driver of Vehicle5: Birthdate1: Date Licensed if Driving 4 Years1: SSN1: Birthdate2: License 2: Date Licensed if Driving 4 Years2: SSN2: Birthdate3: License 3: Date Licensed if Driving 4 Years3: SSN3: Birthdate4: License 4: Date Licensed if Driving 4 Years4: SSN4: Birthdate5: License 5: Date Licensed if Driving 4 Years5: SSN5: Full: Off Limited: Off WorkIncome Loss Limit: Off Vehicle 1 Deductible: Off Vehicle 2 Deductible: Off Vehicle 3 Deductible: Off Vehicle 4 Deductible: Off Vehicle 5 Deductible: Off Rejected: Off Stacked: Off NonStacked: Off Rejected_2: Off Stacked_2: Off NonStacked_2: Off Funeral Benefit: Off Vehicle 1 Deductible_2: Off Vehicle 2 Deductible_2: Off Vehicle 3 Deductible_2: Off Vehicle 4 Deductible_2: Off Vehicle 5 Deductible_2: Off Vehicle 1: Off Vehicle 2: Off Vehicle 3: Off Vehicle 4: Off Vehicle 5: Off Vehicle 1_2: Off Vehicle 2_2: Off Vehicle 3_2: Off Vehicle 4_2: Off Vehicle 5_2: Off Vehicle 1_3: Off Vehicle 2_3: Off Vehicle 3_3: Off Vehicle 4_3: Off Vehicle 5_3: Off Vehicle 1_4: Off Vehicle 2_4: Off Vehicle 3_4: Off Vehicle 4_4: Off Vehicle 5_4: Off Vehicle 1_5: Off Vehicle 2_5: Off Vehicle 3_5: Off Vehicle 4_5: Off Vehicle 5_5: Off Make1: Year1: Year2: Year3: Year4: Year5: Name: Address: City: State: Zip: Phone#: Email: Current Ins: Co:

    VIN 1: Current Policy Exp: Date:

    VIN 5: Garaging Elsewhere Address: Titleholders: Lessor Clause: Business Use Description: License 1: Name1: Name2: Name3: Name4: Name5: Own Home: Off garaging address yes: Off garaging address no: Off titled yes: Off titled no: Off financed yes: Off financed no: Off leased yes: Off leased no: Off garage 1: Off garage 2: Off garage 3: Off garage 4: Off garage 5: Off leased 1: Off leased 2: Off leased 3: Off leased 4: Off leased 5: Off titled 1: Off titled 2: Off titled 3: Off titled 4: Off titled 5: Off financed 1: Off financed 2: Off financed 3: Off fin