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Policy Requested:
What Coverage Protection do you wish?
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State Minimum
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Personal:
What is your date of birth?
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What is your gender?
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What is your occupation?
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What is your marital status?
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What is your education level?
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What is your credit rating?
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What is your type of residence?
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Who is the Applicant?
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What is the Status of your License?
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Where did you get your License?
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Age when received the license?
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21
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90
91
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93
94
95
96
97
98
99
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Was your License ever suspended or revoked?
No
Yes
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Is a SR22 Filing required?
No
Yes
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For how many years you work for your Employer?
0
1
2
3
4
5
6
7
8
9
10
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60
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Vehicle:
Vehicle Year
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1963
1962
1961
1960
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Vehicle Make
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Vehicle Model
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Vehicle Identification Number
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Are you the Vehicle Owner?
Yes
No
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Type of your Garage?
Car Port
Full Garage
No Cover
On Street
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Primary use of Vehicle?
Commute Work
Commute School
Business
Pleasure
Farm
Government
Other
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Annual Miles with Vehicle
2500
7500
12500
15000
25000
50000
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Comprehensive Deductible
100
250
500
1000
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Collision Deductible
100
250
500
1000
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Tickets:
Did you get a Ticket?
No
Yes
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What was your last Ticket?
Careless Driving
Carpool Lane Violation
Child Not In Car Seat
Defective Equipment
Defective Vehicle (Reduced Violation)
Driving Too Fast For Conditions
Driving Without A License
Excessive Noise
Exhibition Driving
Expired Drivers License
Expired Emmissions
Expired Registration
Failure To Obey Traffic Signal
Failure To Signal
Failure To Stop
Failure To Yield
Following Too Close
Illegal Lane Change
Illegal Passing
Illegal Turn
Illegal Turn On Red
Illegal U Turn
Inattentive Driving
No Helmet
No Insurance
No Seatbelt
Passing A School Bus
Passing In A No-Passing Zone
Passing On Shoulder
Ran A Red Light
Ran A Stop Sign
Reckless Driving
Reckless Endangerment
Wrong Way On A One Way
Other
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Ticket Date
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Majorviolations:
Any major Violations Ticket?
No
Yes
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Last major Violation
Driving While Suspended
Drunk Driving - Injury
Drunk Driving - No Injury
Hit And Run - Injury
Hit And Run - No Injury
Reckless Driving - Injury
Reckless Driving - No Injury
Speeding Over 100
Other
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Date of Violation
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Latest major Violation
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PuertoRico
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Accidents:
Did you have any Accidents?
No
Yes
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Description of last Accident
Not Listed
Other Vehicle Hit Yours
Vehicle Damaged Avoiding Accident
Vehicle Hit Pedestrian
Vehicle Hit Property
Vehicle Hit Vehicle
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Date of Accident
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Was it your fault?
No
Yes
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Was any damaged caused?
Not Applicable
People
Property
Both
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Claims:
Do you have any Claims?
No
Yes
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Type of last Claim
Act of Nature
Car fire
Flood damage
Hail damage
Hit an animal
Other
Theft of stereo
Theft of vehicle
Towing service
Vandalism
Windshield Replacement
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Date of Claim
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Amount Paid in USD
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Policy Current:
Are you currently insured?
No
Yes
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What is your current Protection?
Superior
Standard Protection
Basic Protection
State Minimum
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Current Insurance Company
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21st Century
AAA
AARP
AIG
AETNA
AFLAC
AIU
Allied
Allstate
American Alliance Insurance
American Family
American Home Assurance
American Insurance
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American Manufacturers
American Empire Insurance
American Financial
American Health Underwriters
American Mayflower Insurance
American Motorists Insurance
American National
American Premier Insurance
American Protection Insurance
American Automobile Insurance
American Republic
American Savers Plan
American Service Insurance
American Skyline Insurance Company
American Spirit Insurance
American Standard Insurance
AmeriPlan
Amica
Answer Financial
Anthem
Arbella
Armed Forces Insurance
Associated Indemnity
Assurant
Atlanta Casualty
Atlantic Indemnity
Auto Club Insurance Company
AXA Advisors
Bankers Life and Casualty
Banner Life
Best Agency USA
Blue Cross / Blue Shield
Brooke Insurance
Company not listed
Cal Farm Insurance
California State Automobile Association
Chubb
Citizens
Clarendon
CNA
Colonial Insurance
Comparison Market
Continental Insurance
Cotton States
Country Insurance and Financial Services
County Insurance and Financial Services
Countrywide
Countywide
CSE Insurance Group
Dairyland Insurance
eHealth Insurance Services
eHealthInsurance Services
Electric Insurance
Erie Insurance
Esurance
Farm Bureau/Farm Family/Rural
Farmers
FinanceBox.com
Fire and Casualty Insurance Co of CT
Fireman’s Fund
Foremost
Foresters
Geico
GMAC
Golden Rule Insurance
Golden Rule Insurancee
Government Employees Insurance
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Guaranty National Insurance
Guide One Insurance
Hanover Lloyd’s Insurance Company
The Hartford
Health Benefits Direct
Health Choice One
Health Plus of America
HealthShare American
Humana
IFA Auto Insurance
IGF Insurance
Infinity Insurance
Insurance Insight
Insurance.com
Integon
John Hancock
Kaiser Permanente
Kemper Lloyds Insurance
Landmark American Insurance
Leader Insurance
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Liberty National
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MetLife Auto and Home
Metropolitan Insurance Co.
Mid Century Insurance
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Patriot General Insurance
Peak Property and Casualty Insurance
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Physicians
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Response Insurance
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Shelter
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