Auto Insurance Quote Request Please complete accurately for the best possible quote Name: Mailing Address: City:    State: ZIP: E-mail Address: Home Phone: Work Phone: Occupation: Homeowner: Yes    No Do you have Auto Ins. now?: Yes    No Current Auto Insurance Company: Years Insured Expiration date of current policy: Auto Number One Year: Make: Model: Description (2/4 door; 4x4; 4,6 or 8 cyl): VIN ID #: Miles driven to work/school: Do you commute to New Jersey? Yes    No Auto Number Two Year: Make: Model: Description (2/4 door; 4x4; 4,6 or 8 cyl): VIN ID #: Miles driven to work/school: Do you commute to New Jersey? Yes    No List all drivers in your household including yourself: Name: D.O.B.: Male   Female      Single   Married Number of years licensed? Over the last 3 years Number of at-fault accidents Major Violations: *Example: DUI, suspended license, driving with suspended license, ect... Minor Violations: *Example: Speeding, failure to yield, etc... Comprehensive Claims: Driver Number 2 Name: D.O.B.: Male   Female      Single   Married Number of years licensed? Over the last 3 years Number of at-fault accidents Major Violations: *Example: DUI, suspended license, driving with suspended license, ect... Minor Violations: *Example: Speeding, failure to yield, etc... Comprehensive Claims: Driver Number 3 Name: D.O.B.: Male   Female      Single   Married Number of years licensed? Over the last 3 years Number of at-fault accidents Major Violations: *Example: DUI, suspended license, driving with suspended license, ect... Minor Violations: *Example: Speeding, failure to yield, etc... Comprehensive Claims: Check here if there are more then 3 drivers *If there are other people of legal age to drive in your home, please describe in notes at bottom. Desired Coverage Bodily Injury & Property Damage Liability: 15/30/5 25/50/10 50/100/25 100/300/50 250/500/100 300CSL 500CSL Uninsured & Underinsured Motorist Bodily Liability: 15/30 25/50 50/100 100/300 250/300 Medical Payments: 5,000 10,000 25,000 50,000 100,000 higher Other Coverage Accidental Death:     yes Income Loss:     yes Funeral Benefits:     yes Comprehensive: Yes     No Deductible: 100      250      500      1,000 Which Vehicle: Vehicle 1 Vehicle 2 Both Collision: Yes     No Deductible: 100      250      500      1,000 Which Vehicle: Vehicle 1 Vehicle 2 Both Towing: $50 per disablement      $75 per disablement Rental: yes Discount Information Are you a member of Two Rivers Area Chambers of Commerce? yes     no Are you a member of AAA? yes     no Do you wish to pay in full? yes     no Automatic Seatbelts: None Vehicle 1 Vehicle 2 Both Air Bags: None Vehicle 1 Vehicle 2 Both Anit-Lock Brakes: None Vehicle 1 Vehicle 2 Both Progressive does a financial score to determine the best rate. Would you like us to quote you with Progressive? Yes     No If yes, please enter your Social Security Number: We offer Auto - Home Packages Would you like your auto rate to reflect a multi-policy discount? Yes     No Your Homeowners must be written with us in order to qualify. We offer a Catastrophe Liability Policy (umbrella). If we insure your auto's would you like this additional coverage? Yes     No If yes- How many homes do you own? How many rental properties? How many unincorporated bussiness? How many recreational vehicles? Notes or Additional Coverage Desired: