A standard Homeowner's Policy usually consists of the following coverages:

Bodily Injury Coverage
provides provides protection against accidental injury or death of another person if caused by you in an automobile accident.

Property Damage Coverage
provides protection against accidental damage of other people’s property if caused by you while driving. This coverage also provides you with legal defense if another party files a lawsuit against you.

Collision Coverage
provides protection in the event your car is involved in a collision with another vehicle or object, regardless of who is at fault.

Comprehensive Physical Damage
provides protection against losses resulting from damage to your car by fire, flood or animals. This coverage also provides supplemental payments for transportation expenses in the event your insured vehicle is stolen.

Medical Payments, No-Fault or Personal Injury
protection coverage pays the medical expenses of the injured driver and passengers in your car. There may also be coverage if you are hit by a car.

Uninsured/Underinsured Motorists’
provides pays for your injuries caused by an uninsured driver.

Auto Insurance Quote Form

Name
Address
City, State, Zip
Phone Number (Home)
Phone Number (Work)
Email Address
Occupation of Insured
Employer
Date of Birth	( mm/dd/year)
Occupation of Spouse/Employer
Spouse's Employer
Date of Birth
Make of Car (1) Serial Number
Make of Car (2) Serial Number
Make of Car (3) Serial Number
Miles One Way To Work & Annual Mileage - Car 1
Miles One Way To Work & Annual Mileage - Car 2
Miles One Way To Work & Annual Mileage - Car 3
What is Car (1) Used Most For?
What is Car (2) Used Most For?
What is Car (3) Used Most For?
Anti-lock Brakes?	Yes No
Air Bags?	Yes No
Anti-theft Device (active, passive, alarm only, lojack, glass etching)
How many people live in household?
Any Accidents In The Past 5 Years? If yes, please explain in full	Yes No
Any Violations In The Past 5 Years? If yes, please explain in full	Yes No
Do You Own Your Own Home?	Yes No
Current Insurance
Expiration Date
Is Your Current Policy Being Cancelled? If yes, please give reason for cancellation	Yes No
Coverage Required - Bodily Injury Liability	$15,000/$30,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Coverage Required - Personal Injury Payment Medical Expense Limit	$15,000 $50,000 $175,000 $150,000 $250,000
Coverage Required - Physical Damage	$5,000 $10,000 $25,000 $50,000 $100,000
Coverage Required - Physical Damage	$5,000 $10,000 $25,000 $50,000 $100,000
Coverage Required - Medical Deduction	$250 $500 $1,000 $2,000
Lawsuit Threshold (aka Verbal Threshold - cannot sue)
No Threshold (aka Zero Tort - option to sue
Comprehensive Deductible - Car 1	$200 $100 $500 No Comp.
Comprehensive Deductible - Car 2	$100 $200 $500 No Comp.
Comprehensive Deductible - Car 3	$100 $200 $500 No Comp.
Collision Deductible - Car 1	$100 $200 $500 No Collision
Collision Deductible - Car 2	$100 $200 $500 No Collision
Collision Deductible - Car 3	$100 $200 $500 No Collision
Remarks

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