Be specific to tell if accidents
are "at-fault" or "NOT-at-fault" - (carriers require
proof on NOT-at-fault accidents); Also, be specific as
to TYPE of violations, and approximate DATES of each in
the fields below:
Number
& Type of Accidents last 3 years:
Number
& Type of MINOR violations last 3 years:
Number
& Type of MAJOR violations last 3 years:
MN Drivers
License #:
Does
Driver need an SR22 FILING?
Yes
No
If YES
to SR22 filing, why needed? (list
accident/cite)
DRIVER INFORMATION #2
(if none, leave
blank)
Name:
Birthdate:
Sex:
Social Security #:
Be specific to tell if accidents
are "at-fault" or "NOT-at-fault" - (carriers require
proof on NOT-at-fault accidents); Also, be specific as
to TYPE of violations in fields
below:
Number
& Type of Accidents last 3 years:
Number
& Type of MINOR violations last 3 years:
Number
& Type of MAJOR violations last 3 years:
MN Drivers License #:
Does
Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
If More than 2 Drivers, list
Additional Driver's Names, Birthdates, and driving
record history here:
VEHICLE #1
INFORMATION (if "Non-Owners", type
"NON-OWNER" in "YEAR" Field)
Year of
vehicle:
Make &
Model:
Vehicle ID# (for
rating accuracy):
Annual
Mileage:
Used in
business? (Explain, if yes):
VEHICLE #1
COVERAGES:
Select
Liability Limits
Select
Comprehensive Deductible:
Select
Collision Deductible:
Uninsured
Motorists Coverage?
YES NO
Rental
Car & Towing Coverage?
YES NO
Medical
and/or PIP Coverage?
YES NO
VEHICLE #2 INFORMATION
(if none, leave blank)
Year of
vehicle:
Make &
Model:
Vehicle ID# (for
rating accuracy):
Annual
Mileage:
Used in
business? (Explain, if yes):
VEHICLE #2
COVERAGES:
Select
Liability Limits
- - - Liability Limits Must Match Vehicle
#1 - - -
Select
Comprehensive Deductible:
Select
Collision Deductible:
Uninsured
Motorists Coverage?
YES NO
Rental
Car & Towing Coverage?
YES NO
Medical
and/or PIP Coverage?
YES NO
Comments or Remarks: (List additional
drivers, autos, etc. here)
If More than 2 Vehicles or Drivers, list
Additional Vehicles Year, Makes, and Models, and
Driver's Ages and Driving records here:
Send my quotation via:
E-Mail
Fax Regular Mail Call me by Phone!
Thank you for filling out
this form COMPLETELY!
We value your input as PRIVATE
information. Every step has been taken to insure your
privacy, security, and our intent is to release quote
information only to you. We will not give your data to
ANY other person or group for sales, marketing, or ANY
other purposes. By checking the box below you agree to
allow our agency to release this information via the
method you have chosen, and to release us from any
liability should this information be accidentally viewed
by others. Our intention is to maintain your complete
privacy.
Yes, I
Agree. Please Send Me an Auto Quote
NOW!
Click
Button Below When Done
Please
Click Only Once . . . May take up to 30 seconds!
