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Please complete the following form and click the "Send Quote" button for a free Auto Insurance quote. Fields in Yellow are required.
Name:
Address:
City:
Country:
State:
Pennsylvania
Home Telephone Number:
Work Telephone Number:
Cell Phone:
Fax Number:
Email Address:
Vehicle Description
Vehicle #1
(Year, Make & Model):
VIN# (if available):
Vehicle #2
(Year, Make & Model):
VIN# (if available):
Vehicle #3
(Year, Make & Model):
VIN# (if available):
Vehicle Use
Vehicle #1:
----- Select -----
Pleasure
Commute to work - 1 to 5 miles one way
Commute to work - 6 to 10 miles one way
Commute to work - 11 to 14 miles one way
Commute to work - 15 to 20 miles one way
Commute to work - 21 to 30 miles one way
Commute to work - 31 or more miles one way
Business Use
Vehicle #2:
----- Select -----
Pleasure
Commute to work - 1 to 5 miles one way
Commute to work - 6 to 10 miles one way
Commute to work - 11 to 14 miles one way
Commute to work - 15 to 20 miles one way
Commute to work - 21 to 30 miles one way
Commute to work - 31 or more miles one way
Business Use
Vehicle #3:
----- Select -----
Pleasure
Commute to work - 1 to 5 miles one way
Commute to work - 6 to 10 miles one way
Commute to work - 11 to 14 miles one way
Commute to work - 15 to 20 miles one way
Commute to work - 21 to 30 miles one way
Commute to work - 31 or more miles one way
Business Use
Annual miles driven:
Under 25K
Over 25K
Liability Limit (Bodily/Property Damage):
----- Select -----
$15,000/$30,000/$10,000
$25,000/$50.000/$25,000
$50,000/1000,000/$50,000
$100,000/$300,000/$100,000
$250,000/$500,000/$250,000
Medical Expense Coverage:
----- Select -----
$5,000
$25,000
$50,000
$100,000
Driver Information
Name
DOB
Married/Single
M/F
License #
1.
2.
3.
4.
5.
Do you currently have insurance?
Yes
No
If YES, Name of Insurance Company:
How many years have you been licensed?
Number of years licensed in PA?
How many yrs. have you been a US resident?
Have you or any member of your household been arrested?
Yes
No
Have you or any member of your household had any of the following in the past three (3) years?
Yes
No
Speeding Tickets?
Yes
No
If yes, how many?
Moving Violations?
Yes
No
If yes, how many?
A License Suspension?
Yes
No
If yes, when was your license reinstated?
DUI's?
Yes
No
If yes, when was your license reinstated?
Any Accidents? At fault or not at fault?
Yes
No
Describe Accidents here:
COMPREHENSIVE COVERAGE
Vehicle #1:
----- Select -----
No Coverage
$100 deductible
$250 deductible
$500 deductible
$1,000 deductible
Vehicle #2:
----- Select -----
No Coverage
$100 deductible
$250 deductible
$500 deductible
$1,000 deductible
Vehicle #3:
----- Select -----
No Coverage
$100 deductible
$250 deductible
$500 deductible
$1,000 deductible
COLLISION COVERAGE
Vehicle #1:
----- Select -----
$250
$500
$1000
Vehicle #2:
----- Select -----
$250
$500
$1000
Vehicle #3:
----- Select -----
$250
$500
$1000
UNINSURED MOTORISTS
Vehicle #1:
----- Select -----
$15,000-$30,000
$25,000-$50,000
$50,000-$100,000
$100,000-$300,000
$250,000-$500,000
Vehicle #2:
----- Select -----
$15,000-$30,000
$25,000-$50,000
$50,000-$100,000
$100,000-$300,000
$250,000-$500,000
Vehicle #3:
----- Select -----
$15,000-$30,000
$25,000-$50,000
$50,000-$100,000
$100,000-$300,000
$250,000-$500,000
Stacked
Unstacked
UNDERINSURED MOTORISTS
Vehicle #1:
----- Select -----
$15,000-$30,000
$25,000-$50,000
$50,000-$100,000
$100,000-$300,000
$250,000-$500,000
Vehicle #2:
----- Select -----
$15,000-$30,000
$25,000-$50,000
$50,000-$100,000
$100,000-$300,000
$250,000-$500,000
Vehicle #3:
----- Select -----
$15,000-$30,000
$25,000-$50,000
$50,000-$100,000
$100,000-$300,000
$250,000-$500,000
Stacked
Unstacked
Income Loss:
----- Select -----
$1,000 for 5 months
$1,000 for 15 months
$1,500/month up to $25,000
$2,500/month up to $50,000
$5,000/month up to $100,000
Accidental Death:
----- Select -----
$5,000
$10,000
$25,000
Tort Option:
----- Select -----
Full
Limited
Funeral:
----- Select -----
$1,500
$2,500
Include Coverage for Towing & Labor ?
Yes
No
Include Rental Reimbursement Coverage?
Yes
No
Rental Reimbursement Coverage Amount
----- Select -----
$20/day
$25/day
$30/day
$35/day
$40/day
Do any of your vehicles have airbags?
Vehicle #1:
----- Select -----
None
One
Two
Vehicle #2:
----- Select -----
None
One
Two
Vehicle #3:
----- Select -----
None
One
Two
Antilock Brakes?
Vehicle #1
Vehicle #2
Vehicle #3
Anti-theft alarm system?
Vehicle #1
Vehicle #2
Vehicle #3
ADDITINAL INFORMATION
Do you currently have insurance?
Yes
No
What is the expiration date of your current policy?
What are your current liability limits?
----- Select -----
$25,000/$50,000
$50,000/$100,000
$100,000/$300,000
$300,000/$300,000
$250,000/$500,000
Please list all claims for the prior 3 years:
How Did You Hear About Us?
Additional Comments
How do you want to recieve your quote?
Via E-mail
Fax
Telephone
Online Help Desk
Peterson Insurance Services, Inc.
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