Questionnaire

Auto Coverage
Coverages Desired Coverage: *
Liability only: $50,000 Combined Single Limit, $2,000 Medical Payments coverage
Liability Coverage Plus: Same as Liability Only, plus Fire, Theft, Vandalism with a Deductible of $250 & Collision with a Deductible of $500.

Coverage Period Desired *
Vehicle Info Model Year of Vehicle *
Value of Vehicle (vehicle values can be looked up on Kelley Blue Book) *
Elgibility Questions Have any drivers that will be covered been involved in more than one motor vehicle accident or violation in the past three years?
Have you or has any driver that will be covered had automobile insurance declined cancelled in the past three years?
Are you or any driver that will be covered under 25 years of age or over 75 years of age?
Does the described vehicle have any cracked or broken glass or other safety deficiency?
Do you or does any driver of this vehicle have a physical or mental deficiency or impairment?
Have you or has any driver that will be covered had a license revoked, suspended or refused?
Have you or any driver that will be covered been convicted of driving under the influence of drugs or alcohol (DWI, DUI) or hit and run?
Are you or is any driver that will be covered a U.S. or Canadian citizen?
Have you been licensed for less than two years?
Is the vehicle registered in Massachusetts, New Jersey, South Carolina or North Carolina?
Is the vehicle used for business or commercial purposes?
Is the vehicle valued at more than US $25,000 or does it have more than 200 horsepower?
Is the vehicle considered a Sports Car or High Performance Vehicle?
Is the vehicle rented or borrowed?
If you would like the policy express mailed to you, check this box: