Have
the following information available when requesting price quotations.
Be sure to mention your qualifications for any discounts and tell the insurer
if your car has safety features or anti-theft devices.
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| Year | |
| Manufacturer | |
| Model | |
| Body Style | |
| Vehicle ID Number | |
| Car Location (city/county/state/zip) | |
| Number of miles normally driven each year | |
| Vehicle's primary use: (work, school, pleasure,farm, business) | |
| Number of miles to and from work |
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| Name | |
| Relationship to applicant | |
| Date of Birth | |
| Sex | |
| Marital Status | |
| Occupation | |
| Number of convictions for moving violations in
past three years
(Be prepared to give details) |
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| Number of accidents in the past three years (Be prepared to give details) |
Coverages And Minimum Recommended Limits*
To
compare cost for coverage, complete the following form for each quotation
received. Be sure to clarify if the premiums quoted are annual or
semiannual. Also ask about discounts, dividends or credits that may
apply.
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| Bodily Injury Liability, $250,000/$500,000* | $ | $ | $ |
| Property Damage, $100,000 | $ | $ | $ |
| Medical Payments, $5,000, or Personal Injury Protection* | $ | $ | $ |
| Uninsured/Underinsured Motorist Coverage, as required by state | $ | $ | $ |
| Collision, with $500 deductible | $ | $ | $ |
| Comprehensive, with $500 deductible | $ | $ | $ |
| Other | $ | $ | $ |
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