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*Name:
*Address:
*City:
*State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tenessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*Zip:
*Home Phone:
Work Phone:
Cell Phone:
E-mail:
*Current Carrier:
*# of Yrs w/Co:
Policy #:
Exp Date:
*Non-Renewed?
Yes
No
If so, why?
*Any LAPSE in
coverage over
the last 3 years?
Yes
No
*Any policy
Cancelled for
Non-Payment
within the last
3 years?
Yes
No
CURRENT BI/PD LIMITS
Vehicle #1:
*Year:
*Make:
*Model:
2dr
4dr
Convertible
*VIN:
Alarm/Wetch:
Yes
No
*Annual Mileage:
< 10,000 mi
10,000 mi
15,000 mi
15,000+ mi
*Registered Owner:
Yes
No
*Loan/Lease:
Yes
No
*Garaged at address
other than above?:
Yes
No
*Princ/Occas
Operator:
Yes
No
*Use:
Personal
Business
Commuting
*Mileage to Work
(One-Way):
*Collision
Deductible:
None
$100
$500
$750
$1,000
$1,500
$2,000
*Compensation
Deductible:
None
$100
$500
$750
$1,000
$1,500
$2,000
Add another vehicle
Vehicle #2:
*Year:
*Make:
*Model:
2dr
4dr
Convertible
*VIN:
Alarm/Wetch:
Yes
No
*Annual Mileage:
< 10,000 mi
10,000 mi
15,000 mi
15,000+ mi
*Registered Owner:
Yes
No
*Loan/Lease:
Yes
No
*Garaged at address
other than above?:
Yes
No
*Princ/Occas
Operator:
Yes
No
*Use:
Personal
Business
Commuting
*Mileage to Work
(One-Way):
*Collision
Deductible:
$100
$500
$750
$1,000
$1,500
$2,000
*Compensation
Deductible:
$100
$500
$750
$1,000
$1,500
$2,000
Add another vehicle
Vehicle #3:
*Year:
*Make:
*Model:
2dr
4dr
Convertible
*VIN:
Alarm/Wetch:
Yes
No
*Annual Mileage:
< 10,000 mi
10,000 mi
15,000 mi
15,000+ mi
*Registered Owner:
Yes
No
*Loan/Lease:
Yes
No
*Garaged at address
other than above?:
Yes
No
*Princ/Occas
Operator:
Yes
No
*Use:
Personal
Business
Commuting
*Mileage to Work
(One-Way):
*Collision
Deductible:
$100
$500
$750
$1,000
$1,500
$2,000
*Compensation
Deductible:
$100
$500
$750
$1,000
$1,500
$2,000
Add another vehicle
Vehicle #4:
*Year:
*Make:
*Model:
2dr
4dr
Convertible
*VIN:
Alarm/Wetch:
Yes
No
*Annual Mileage:
< 10,000 mi
10,000 mi
15,000 mi
15,000+ mi
*Registered Owner:
Yes
No
*Loan/Lease:
Yes
No
*Garaged at address
other than above?:
Yes
No
*Princ/Occas
Operator:
Yes
No
*Use:
Personal
Business
Commuting
*Mileage to Work
(One-Way):
*Collision
Deductible:
$100
$500
$750
$1,000
$1,500
$2,000
*Compensation
Deductible:
$100
$500
$750
$1,000
$1,500
$2,000
DRIVERS
All residents in household age 13 & over(even if they have their own cars and insurance)
Driver #1:
*Name:
*DOB:
*Marital Status:
Single
Married
Divorced / Widowed
*Yrs Licensed in US:
*License suspended
within the last
3 years?:
Yes
No
If so, why? :
*Student away at
school over 100 mi
without a car?:
Yes
No
If so, why? :
*Accidents /
Violations /
Comprehensive
Claims (within the
last 5 years)?:
Yes
No
Add another driver
Driver #2:
*Name:
*DOB:
*Marital Status:
Single
Married
Divorced / Widowed
*Yrs Licensed in US:
*License suspended
within the last
3 years?:
Yes
No
If so, why? :
*Student away at
school over 100 mi
without a car?:
Yes
No
If so, why? :
*Accidents /
Violations /
Comprehensive
Claims (within the
last 5 years)?:
Yes
No
Add another driver
Driver #3:
*Name:
*DOB:
*Marital Status:
Single
Married
Divorced / Widowed
*Yrs Licensed in US:
*License suspended
within the last
3 years?:
Yes
No
If so, why? :
*Student away at
school over 100 mi
without a car?:
Yes
No
If so, why? :
*Accidents /
Violations /
Comprehensive
Claims (within the
last 5 years)?:
Yes
No
Add another driver
Driver #4:
*Name:
*DOB:
*Marital Status:
Single
Married
Divorced / Widowed
*Yrs Licensed in US:
*License suspended
within the last
3 years?:
Yes
No
If so, why? :
*Student away at
school over 100 mi
without a car?:
Yes
No
If so, why? :
*Accidents /
Violations /
Comprehensive
Claims (within the
last 5 years)?:
Yes
No
Disclaimer:
Quote will be based on information provided by Applicant. Actual policy premium may differ after MVR/CLUE/Credit reports are obtained.
Privacy:
Hekemian & Co., Inc. and each of its affiliates are committed to protecting your privacy. We use the information we collect about you to provide an accurate quote. Hekemian & Co., Inc. does not transfer, disclose, sell, trade, or rent your personal information to others. We will not disclose or send promotional mail to customer addresses (regular or e-mail) unless such service is specifically requested by the customer.
