List the names of all drivers living in your household.
For each driver, please indicate the number of at-fault accidents, the
number of minor moving traffic violations (such as speeding, illegal turns),
and any major violations (such as driving under the influence, reckless
driving, driving with a suspended license) occurring within the last three
years by the driver.
Driver #1
Accidents
None
One
Two
Three
More Than Three
Minor Violations
None
One
Two
Three
More Than Three
Major Violations
None
One
Two
Three
More Than Three
Driver #2
Accidents
None
One
Two
Three
More Than Three
Minor
Violations
None
One
Two
Three
More Than Three
Major
Violations
None
One
Two
Three
More Than Three
Please list the vehicles currently driven by individuals
living in your household. Please note that the following types of vehicles
are not insurable: Mopeds, Engine size less than 251 cc, Kit or
self-constructed motorcycles, Salvaged or rebuilt motorcycles.
Bodily Injury
$20,000 / $40,000 Per Person/Per Accident
$35,000 / $70,000 Per Person/Per Accident
$50,000 / $100,000 Per Person/Per Accident
$100,000 / $300,000 Per Person/Per Accident
$300,000 / $300,000 Per Person/Per Accident
Property Damage
$10,000
$15,000
$20,000
$25,000
$30,000
$50,000
$100,000
UM Coverage
I reject uninsured coverage for this policy and any
renewal policy.
$20,000 per person /
$40,000 per accident
UIM Coverage
I reject uninsured coverage for this policy and any
renewal policy.
$20,000 per person
$40,000 per accident
Medical Payments
Op $1,000 Limit; $100 Ded/Pass $1,000 Limit; $100 Deductible
Op $5,000 Limit; $500 Ded/Pass $1,000 Limit; $100 Deductible
Op $15,000 Limit; $1,500 Ded/Pass $1,000 Limit; $100 Deductible
Op $10,000 Limit; $-0- Ded/Pass $1,000 Limit; $100 Deductible
Op $15,000 Limit; $-0- Ded/Pass $1,000 Limit; $100 Deductible
Please indicate how we can
best contact you
Email
Phone Call
Regular Mail
Fax
