Liability Limit For ALL Cars

Choose either   Bodily Injury   and   Property Damage

Bodily Injury $25,000/50,000 $50,000/100,000 $100,000/300,000 $250,000/500,000   Property Damage $25,000 $50,000 $100,000 $500,000

or   Single Limit

Single Limit $60,000 $100,000 $300,000 $500,000

Deductibles and Misc.

Car#

Comprehensive Deductible

Collision Deductible

Towing

Loss of Use

1

$250 $500 $1000

Yes

Yes

2

$250 $500 $1000

Yes

Yes

Driver Information

(include all licensed drivers in your household)

Driver 1

Driver's Name

Drivers License Information

DL#:   State:   Years Licensed:

Relation

Date of Birth

Sex

Marital Status

Courses Completed Last 3 yrs

M   F

Married  Single

                  Drivers Ed: Y N
Accident Prevention: Y N

Driver Information

(include all licensed drivers in your household)

Driver 2

Driver's Name

Drivers License Information

DL#:   State:   Years Licensed:

Relation

Date of Birth

Sex

Marital Status

Courses Completed Last 3 yrs

M   F

Married  Single

                  Drivers Ed: Y N
Accident Prevention: Y N

Driver Information

(include all licensed drivers in your household)

Driver 3

Driver's Name

Drivers License Information

DL#:   State:   Years Licensed:

Relation

Date of Birth

Sex

Marital Status

Courses Completed Last 3 yrs

M   F

Married  Single

                  Drivers Ed: Y N
Accident Prevention: Y N

Driver History

Please list ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years

Driver

Date

Type of Conviction

Fines

Speed Over Limit

$

mph

$

mph

$

mph