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 dzLJƻƴ purchase ƻŦ 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 dzLJƻƴ purchase ƻŦ 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