Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Year
Make
Model
Vehicle ID *17 digit number with letters and
numbers
Style
2 Door
4 Door
Convertible
2 Door
4 Door
Convertible
2 Door
4 Door
Convertible
2 Door
4 Door
Convertible
Customized Vehicle
Yes
No
Yes
No
Yes
No
Yes
No
If yes, value of customization
NONE
$1-$4,999
$5,000-$9,999
$10,000-$14,999
$15,000-$19,999
$20,000-$24,999
$25,000-$29,999
NONE
$1-$4,999
$5,000-$9,999
$10,000-$14,999
$15,000-$19,999
$20,000-$24,999
$25,000-$29,999
NONE
$1-$4,999
$5,000-$9,999
$10,000-$14,999
$15,000-$19,999
$20,000-$24,999
$25,000-$29,999
NONE
$1-$4,999
$5,000-$9,999
$10,000-$14,999
$15,000-$19,999
$20,000-$24,999
$25,000-$29,999
Anti Lock Brakes
NONE
2 Wheels
4 Wheels
NONE
2 Wheels
4 Wheels
NONE
2 Wheels
4 Wheels
NONE
2 Wheels
4 Wheels
Air Bag(s)
Drivers side only
Dual air bags
Drivers side only
Dual air bags
Drivers side only
Dual air bags
Drivers side only
Dual air bags
Side air bag(s)
NONE
Drivers side only
Both sides front
All doors
NONE
Drivers side only
Both sides front
All doors
NONE
Drivers side only
Both sides front
All doors
NONE
Drivers side only
Both sides front
All doors
Usage*mileages are for work/school, one way
Pleasure (retired)
Homemaker
2 miles or less
3-14 miles
15-29 miles
30-50 miles
51+ miles
Farm use (farmer)
Pleasure (retired)
Homemaker
2 miles or less
3-14 miles
15-29 miles
30-50 miles
51+ miles
Farm use (farmer)
Pleasure (retired)
Homemaker
2 miles or less
3-14 miles
15-29 miles
30-50 miles
51+ miles
Farm use (farmer)
Pleasure (retired)
Homemaker
2 miles or less
3-14 miles
15-29 miles
30-50 miles
51+ miles
Farm use (farmer)
Business Use
NONE
Real estate agent
Sub contractor
In home business
NONE
Real estate agent
Sub contractor
In home business
NONE
Real estate agent
Sub contractor
In home business
NONE
Real estate agent
Sub contractor
In home business
Mail/Newspaper Delivery
Yes
No
Yes
No
Yes
No
Yes
No
Pizza Delivery
Yes
No
Yes
No
Yes
No
Yes
No
Leased Vehicle
Yes
No
Yes
No
Yes
No
Yes
No
Does Vehicle have a loan?
Yes
No
Yes
No
Yes
No
Yes
No
Please provide the desired coverages on each vehicle listed
Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
Bodily Injury
25/50
50/100
100/300
250/500
500/500
100,000 CSL
300,000 CSL
500,000 CSL
1,000,000 CSL
25/50
50/100
100/300
250/500
500/500
100,000 CSL
300,000 CSL
500,000 CSL
1,000,000 CSL
25/50
50/100
100/300
250/500
500/500
100,000 CSL
300,000 CSL
500,000 CSL
1,000,000 CSL
25/50
50/100
100/300
250/500
500/500
100,000 CSL
300,000 CSL
500,000 CSL
1,000,000 CSL
Property Damage
25,000
50,000
100,000
250,000
500,000
25,000
50,000
100,000
250,000
500,000
25,000
50,000
100,000
250,000
500,000
25,000
50,000
100,000
250,000
500,000
Medical Payments
1,000
2,000
5,000
10,000
25,000
50,000
100,000
1,000
2,000
5,000
10,000
25,000
50,000
100,000
1,000
2,000
5,000
10,000
25,000
50,000
100,000
1,000
2,000
5,000
10,000
25,000
50,000
100,000
Uninsured/Underinsured?
Yes
No
Yes
No
Yes
No
Yes
No
Comprehensive
NONE
0 deductible
50 deductible
100 deductible
200 deductible
250 deductible
500 deductible
1000 deductible
NONE
0 deductible
50 deductible
100 deductible
200 deductible
250 deductible
500 deductible
1000 deductible
NONE
0 deductible
50 deductible
100 deductible
200 deductible
250 deductible
500 deductible
1000 deductible
NONE
0 deductible
50 deductible
100 deductible
200 deductible
250 deductible
500 deductible
1000 deductible
Collision
NONE
100 deductible
200 deductible
250 deductible
350 deductible
500 deductible
1000 deductible
NONE
100 deductible
200 deductible
250 deductible
350 deductible
500 deductible
1000 deductible
NONE
100 deductible
200 deductible
250 deductible
350 deductible
500 deductible
1000 deductible
NONE
100 deductible
200 deductible
250 deductible
350 deductible
500 deductible
1000 deductible
Towing
NONE
$50
$75
NONE
$50
$75
NONE
$50
$75
NONE
$50
$75
Rental Reimbursement
NONE
$20 a day
$25 a day
$30 a day
NONE
$20 a day
$25 a day
$30 a day
NONE
$20 a day
$25 a day
$30 a day
NONE
$20 a day
$25 a day
$30 a day
Loan Lease Reimbursement*guarantees to pay off the loan or lease on a new vehicle which has been totaled
Yes
No
Yes
No
Yes
No
Yes
No
