429 Theater Drive ~ Johnstown, PA 15904 ~ Phone (814)-262-9833 ~ Fax (814)-262-9733~1-800-544-6680
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This form will be used to give you a rough estimate for an automobile quote from our company.
Please provide information for every space as it applies:
First names Driver1 Driver2 Driver3 Driver4 Middle initials Driver1 Driver2 Driver3 Driver4 Ages Driver1 Driver2 Driver3 Driver4 Street address Address (cont.) City State/Province Zip/Postal code Work Phone Home Phone E-mail (for response to this email)
Personal Information for Primary Driver:
Middle initial Date of birth Sex Male Female
Marital Status:
Married Single Widowed Divorced Seperated
Do you currently rent or own your residence?
Own Rent
Which residence type best describes your home?
Single Family Duplex (owner only) Condo Townhouse Apartment Mobile Home Other
How long have you lived at your current residence? (if less than a month, enter one month)
How long did you live at your previous residence?
What is your occupation? (if retired, select previous occupation)
Administration/Management Architect Certified Public Accountant Clergy Clerical/Technical College Professor Craftsman/Skilled Worker Dentist Engineer Housewife/Househusband Laborer/Unskilled Worker Lawyer Military Officer Military E1 - E4 Military E5 - E7 Military Other Physician Prof'l w/Specialty Degree Prof'l w/College Degree School Teacher Self Employed Student Living w/Parents Stud. Not Living w/Parents Technical/Supervisory Unemployed
In the last 3 years, has your license been suspended/revoked?
Yes No
Do you need to file a financial responsibility form (SR-22)?
Have you been cited for any violations or involved in any accidents, regardless of fault, in the last 3 years, or experienced any losses in the last 3 years?
How many people living in your household will not be listed as drivers on your policy? (maximum of 9 household members)
Please enter losses in the last 3 years and all violations and accidents, regardless of fault, within the last 3 years. (include loss date, violation/accident/loss type, damage amount, what was damaged ex. people, property, both) List these for every driver and include the driver in the list.
Please list the automobiles that you want covered. Include year, make, modle, cylander.
Cost new (approximate):
City where garaged (must be in PA):
ZIP Code where garaged (must be valid for City):
Registered state:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
How many miles is the vehicle driven annually? (must be in miles)
miles
What is the vehicle primarily used for?
Pleasure Commute Business (Corporate) Business (Individual) Government Farm Use
How many miles is the vehicle driven during one-way commute?
How many days per week is the vehicle used for commuting?
Manufactured for use outside US; Considered a classic; Custom equipment modifications; Extensive unrepaired damage; Has vehicle ever been stolen:
Canopy/Camper Tops; Custom Painting; Special Wheels/Rims; Stereo equipment over $350; Custom Body Work; Van Modifications; Winch
Security System:
None Active Disabling Passive Alarm only Lojack
4 wheel drive:
Anti-lock brakes:
No anti-lock All-wheel anti-lock Rear-wheel only Front-wheel only
Automatic seat belts:
Airbags:
Please choose one... No airbags Driver's & Passenger's side only Driver's side only Passenger's side only Driver's, Passenger's & side impact
Have you ever had auto insurance coverage?
Have you had continuous coverage for at least the last 12 months?
Which best describes your bodily injury limits? (if unknown, check your policy)
No coverage currently State minimum <$50,000/$100,000
Have you ever had comprehensive coverage?
Have you ever had collision coverage?
Who is your prior or current insurance carrier?
AAA Auto Club of Southern California Auto Club South Automobile Club of Michigan California State Automobile Association AIG Allstate Insurance Group American Family Insurance Group Amica Mutual Group Arbella Insurance Group Auto-Owners Group Avomark CNA Insurance Group Commerce Group Commercial Union Insurance Companies Country Companies Erie Insurance Group Farmers Insurance Group GEICO General Accident Group Grange Mutual Casualty GRE Insurance Group Harleysville Insurance Companies Hartford Fire & Casualty Group Horace Mann Group Integon Corporation Kemper Insurance Liberty Mutual Lincoln National Mercury General Group Metropolitan Group Motors Insurance Group Nationwide Insurance New Jersey Manufacturers Ohio Casualty Group Progressive Group Prudential of America Reliance Direct Safeco Insurance Group Sentry Insurance Group Shelter Insurance Companies Southern Farm Bereau Casualty St. Paul Companies State Auto Mutual Group State Farm State Farm Fire & Casualty Travelers Insurance Group Tri-State Consumer Insurance Twentieth Century Insurance Group Unitrin Inc. USAA Group USF&G Group Other
How long have you been with this carrier in years and months?
What is your current policy's expiration date? (If not currently covered, enter the date your last policy expired.)
-- mm/dd/yy
In the last 3 years, has your insurance been canceled or have you been refused insurance?
Bodily Injury Liability:
$15,000/30,000 $30,000/100,000 $100,000/300,000 $250,000/500,000 $500,000/1,000,000
Property Damage Liability:
$5,000 $15,000 $30,000 $50,000 $100,000 $250,000 $500,000
Uninsured Motorist Bodily Injury Liability: (cannot be higher than Bodily Injury Liability requested above)
Underinsured Motorist Bodily Injury Liability: (cannot be higher than Bodily Injury Liability requested above)
PIP-Medical Expense:
$5,000 $10,000 $25,000 $50,000 $100,000 No Coverage
PIP-Loss of Income:
PIP-Accidental Death
PIP-Funeral Expense Benifits:
$2,500 No Coverage Wanted
Comprehensive Deductible:
$0- Coverage w/o Deductable $50 $100 $200 $250 $500 $1,000
Collision Deductible: (Comprehensive Coverage is required for Collision Coverage)
$50 $100 $150 $200 $250 $500 $1,000 No Coverage
Rental Reimbursement:
$15 per day $20 per day $25 per day $30 per day $35 per day $50 per day $75 per day No Coverage
Towing & Labor:
$25 $40 $50 $75 $80 $120 No Coverage
Choose your desired effective date for this policy: (must be today's date or later)
