Personal Auto Quote Form

Auto #1

Auto #2

Auto #3

Auto #4

Year

Make

Model

VIN #

Miles Per Year

Anti-Theft Device

Auto #1

Auto #2

Auto #3

Auto #4

1. Bodily Injury to Others

20,000/40,000

20,000/40,000

20,000/40,000

20,000/40,000

8,000

8,000

8,000

8,000

20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000

4. Damage to Others Property

5,000 10,000 15,000 20,000 25,000 50,000 100,000

Select 5,000 10,000 15,000 20,000 25,000 50,000 100,000

Select 5,000 10,000 15,000 20,000 25,000 50,000 100,000

Select 5,000 10,000 15,000 20,000 25,000 50,000 100,000

5. Opt. Bodily Injury

20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 None

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 None

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 None

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000 None

6. Medical Payments

5,000 10,000 15,000 20,000 25,000 50,000 100,000 None

5,000 10,000 15,000 20,000 25,000 50,000 100,000 None

5,000 10,000 15,000 20,000 25,000 50,000 100,000 None

5,000 10,000 15,000 20,000 25,000 50,000 100,000 None

7. Collision

300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible No Coverage

Select 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible No Coverage

Select 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible No Coverage

Select 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible No Coverage

8. Limited Collision

No Deductible 100 No Coverage

No Deductible 100 No Coverage

No Deductible 100 No Coverage

No Deductible 100 No Coverage

9. Comprehensive

300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible No Coverage

Select 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible No Coverage

Select 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible No Coverage

Select 300 Deductible 500 Deductible 1,000 Deductible 2,000 Deductible No Coverage

10. Substitute Transportation

$15/day ($450 max.) $30/day ($900 max.) No Coverage

Select $15/day ($450 max.) $30/day ($900 max.) No Coverage

Select $15/day ($450 max.) $30/day ($900 max.) No Coverage

Select $15/day ($450 max.) $30/day ($900 max.) No Coverage

11. Towing

$25/disablement $50/disablement No Coverage

Select $25/disablement $50/disablement No Coverage

Select $25/disablement $50/disablement No Coverage

Select $25/disablement $50/disablement No Coverage

12. Underinsured

20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000

Select 20,000/40,000 25,000/50,000 35,000/70,000 50,000/100,000 100,000/300,000 250,000/500,000