On-Line Automobile
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal Data

Your Name:
Street Address:
City:
State: (Must be Pennsylvania)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No If YES to SR22 filing, why needed?
(list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an SR22 FILING?		 Yes No Comments or
Remarks?
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of
Liability:		 $50/100 BI / 50 PD
$100/300 BI / 100 PD
$300,000 CSL
$500,000 CSL
 
Comprehensive
Coverage:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Collision
Coverage:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Uninsured Motorists
Coverage?		 YES NO
 
Rental Car &
Towing Coverage?		 YES NO
 
Medical and/or
PIP Coverage?		 YES NO
 
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of
Liability:		 $50/100 BI / 50 PD
$100/300 BI / 100 PD
$300,000 CSL
$500,000 CSL
 
Comprehensive Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Collision
Coverage:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Uninsured Motorists
Coverage?		 YES NO
 
Rental Car &
Towing Coverage?		 YES NO
 
Medical and/or
PIP Coverage?		 YES NO
 
Do You Want the "Limited Tort" option quoted?
(Under the "Limited Tort' option, you & family members' right to seek financial compensation for injuries caused by other drivers are limited. You cannot sue for pain and suffering unless you sustain a serious or permanent injury, court defined as a "serious impairment of a bodily function".) 		Full Tort Option
(Under the "Full Tort" option, you maintain an unrestricted right for you and the members of your household to seek financial compensation for injuries caused by other drivers.)

Limited Tort Option
(Selection of the "Limited Tort" option will reduce your insurance premium but also reduce available benefits.)
If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:
Comments or Remarks:
(List additional drivers, autos, etc. here)

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