Auto Insurance Form
We provide coverage in the State of Maine and New Hampshire.
Please fill out this form and we will search for the best value for you.  We will respond promptly to you.

First name

 Last name

Employer

Address

 City
 State
 Zip code
Home Phone
Work Phone
FAX
 E-mail
       
Vehicle Information
Vehicle 1
Year/Make/Model Vehicle ID    
   
Antilock Airbags Alarm
2 wheel driver active
4 wheel dual passive
Drive to work or school? If yes, enter miles one way Business or Farm Use?
Yes No Yes No

Comprehensive
(deductible)

Collision(deductible)

Towing and Labor

Rental Reimbursement



50

100

Yes

Yes
100 250 No No
250 500    
Other Other
Other Other
Vehicle 2
Year/Make/Model Vehicle ID    
   
Antilock Airbags Alarm
2 wheel driver active
4 wheel dual passive
Drive to work or school? If yes, enter miles one way Business or Farm Use?
Yes No Yes No

Comprehensive
(deductible)

Collision(deductible)

Towing and Labor

Rental Reimbursement



50

100

Yes

Yes
100 250 No No
250 500    
Other Other
Other Other
Are there any other vehicles in the houseold
Yes
No
   
Driver Information
Driver 1
Full Name
 Sex Marital Status
Male Female Single Married
Birthdate (mm/dd/yy)
B Grade or better student?
Yes No  
Lisence Number
 State Licence issued in

Vehicle Driven Most
Describe any accidents or convictions in the last 3 years
Has your license been suspended in the last 5 years? Yes No

Driver 2
Full Name
 Sex Marital Status
Male Female Single Married
Birthdate (mm/dd/yy)
B Grade or better student?
Yes No  
Lisence Number
 State Licence issued in

Vehicle Driven Most
Describe any accidents or convictions in the last 3 years
Has your license been suspended in the last 5 years? Yes No


Driver 3
Full Name
 Sex Marital Status
Male Female Single Married
Birthdate (mm/dd/yy)
B Grade or better student?
Yes No  
Lisence Number
 State Licence issued in

Vehicle Driven Most
Describe any accidents or convictions in the last 3 years
Has your license been suspended in the last 5 years? Yes No


Driver 4
Full Name
 Sex Marital Status
Male Female Single Married
Birthdate (mm/dd/yy)
B Grade or better student?
Yes No  
Lisence Number
 State Licence issued in

Vehicle Driven Most
Describe any accidents or convictions in the last 3 years
Has your license been suspended in the last 5 years? Yes No


Driver 5
Full Name
 Sex Marital Status
Male Female Single Married
Birthdate (mm/dd/yy)
B Grade or better student?
Yes No  
Lisence Number
 State Licence issued in

Vehicle Driven Most
Describe any accidents or convictions in the last 3 years
Has your license been suspended in the last 5 years? Yes No


Away at school?
Are there any drivers away at school? Yes No if yes, please specify
Is it over 100 miles from Home?   With Car?


Split Limit
*Please select your liability limits for BOTH Bodily Injury AND Property Damage		 Combined Single Limit
*Please select your Combined Single liability limit.
       
Bodily Injury per person/per accident Bodily Injury and Property Damage
50/100,000 $100,000
100/300,000 $300,000
250/500,000 $500,000
Other (please specify) Other (please specify)
   


Uninsured Motorist
Our proposal will include Uninsured Motorist limits equal to the Bodily Injury limits selected above.

Medical Payments Per Person

$1000 $5000 $10000 Other - please specify


Other Comments

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