Coleman Insurance Agency, Inc. -- Automobile Quote Form

Coleman Insurance Agency, Inc.
PA Residence Only


AUTOMOBILE INSURANCE QUOTE		We would like to provide you with a free, no-obligation automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Personal Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM Email Address
Do you own a Home or Rent

Current Auto Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months 1 Year Other:

Vehicle Information
(include all cars you or your family members own or lease)
Car #1	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #2	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #3	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Car #4	Year	Make	Model	Body Type	Vehicle ID# (VIN)

Name of Title Holder		Annual Mileage	Drive to school/work? # of miles		Airbags	Car Alarm
			Y N one way		Y N	Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City: State: Zip:

Deductibles and Misc.
Car#	Comprehensive Deductible	Collision Deductible	Towing	Rental
1			Yes	Yes
2			Yes	Yes
3			Yes	Yes
4			Yes	Yes

Liability Limit For ALL Cars
Choose either Bodily Injury and Property Damage Bodily Injury Property Damage	or Single Limit Single Limit

First Party Benifits
Medical Expense Coverage Extraordinary Medical Coverage Income Loss	Funeral Expense Accidental Death

Additional Informantion
Uninsured and Underinsured Motorist Coverage Stacking Option	Tort Option Option

Driver Information
(include all licensed drivers in your household)
Driver #1	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Social Security #
		M F	Married Single	SS#

Driver #2	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Social Security #
		M F	Married Single	SS#

Driver #3	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Social Security #
		M F	Married Single	SS#

Driver #4	Driver's Name		Drivers License Information
			DL#: State: Years Licensed:
Relation	Date of Birth	Sex	Marital Status	Social Security #
		M F	Married Single	SS#

Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violations* in the past 3 years*
Driver	Date	Type of Conviction	Fines	Speed Over Limit
			$	mph
			$	mph
			$	mph
			$	mph

Please list ANY driver who has had license suspensions, revocations or DUI convictions* below*
Driver	License Suspended or Revoked	DUI Conviction For:
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs

Please list ANY driver involved in any accidents or Comprehensive Claims, regardless of fault, in the past 5 years
Driver	Date	Description	Cost	Fines	Injuries	At Fault
			$	$	Yes	Yes
			$	$	Yes	Yes
			$	$	Yes	Yes
			$	$	Yes	Yes

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.
PA Residence only