Drivers
| Driver | Age | Sex | Marital Status | % Use of Vehicle |
|---|---|---|---|---|
| Principal Operator | ||||
| Other Drivers | ||||
| Other Drivers |
Other Information for Quote
Annual Mileage:
Number of days per week or weeks out of 5 weeks if driving in a car pool:
Number of miles one way if driving to and from work every day:
Number of accidents of moving violations in the last 3 years
List on separate sheet. Use date of conviction for violations.
Type of auto(s) to be insured
| ID | Make | Model | Year |
|---|---|---|---|
| Auto 1 | |||
| Auto 2 |
Insurance Coverage
| Coverage | Limits or Deductibles | Company 1 Annual Premiums | Company 2 Annual Premiums | Company 3 Annual Premiums | Company 4 Annual Premiums |
|---|---|---|---|---|---|
| Liability (per person) | $ | $ | |||
| Bodily Injury (per accident) | $ | $ | |||
| Property Damage (per accident) | $ | $ | |||
| Uninsured Motorist | |||||
| Liability | $ | $ | |||
| Bodily Injury (per accident) | $ | $ | |||
| Physical Damage to Insured Vehicle | $ | $ | |||
| Comprehensive Deductible | $ | $ | |||
| Comprehensive (per accident) | $ | $ | |||
| Collision (per accident) | $ | $ | |||
| Other Coverages | $ | ||||
| Total Annual Premium | $ | ||||
| Membership Fees (if applicable) | $ | ||||
| Installment Premium Plan | $ | ||||
| Total Cost of Auto Insurance | $ | $ | $ | $ | |