Quote Information:

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Zip Code
License #
Social Security #
License #
Social Security #
Birth Date
License #
Social Security #
Birth Date
License #
Social Security #
Birth Date
Drivers Violations in the last 3 Years and Accidents in the last 5 Years  
Driver #1
Driver #2
Driver #3
Any Claims in the last 3 years Yes No  If yes, please specify:
Motorcycle #1 Year:: Make: Model: VIN#
Motorcycle #2 Year:: Make: Model: VIN#


Bodily Injury: {If you injure someone else not in your auto} 25,000/50,000     50,000/100,000 

100,000/300,000     250,000/500,000

Property Damage: {Damage you do to others with your vehicle}  

25,000 50,000 100,000

Medical Payments: {Pays for injury to you or your passengers}  

1000 2000 500010,000

Uninsured & Underinsured Motorist: {This covers you and your passengers in the event of an accident that is the fault of another party but they don't have any insurance or not enough insurance to cover you and your passengers medical bills and expenses} 25,000/50,000 50,000/100,000

 100,000/300,000 250,000/500,000

Comprehensive Deductible:

100 250 50010002000
Collision Deductible: 250 50010002000
Emergency Road Service / Towing Yes No
Rental Reimbursement: Yes No
SR-22 Form: {This form is needed if your license was suspended or revoked and the State is requiring this before you can get your license back.} Yes No
Have you currently been insured for at least 6 consecutive months? Yes No
Name of Present Insurance Company
Expiration Date:
Has your license been suspended or revoked in the last 5 years:: Yes No
Are there other residents in the household over the age of 14 NOT listed on this quote: Yes No
Rent or Own Home Rent Own

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Advantage Insurance Agency
Copyright 1999 [Advantage Insurance]. All rights reserved.
Revised: January 23, 2010 .