Personal Auto Insurance Quote Form

Personal Auto
Quote Form

-   PA and OH only

   -   The "ENTER" or "RETURN" Key will submit the application.   Use the "TAB" Key and Mouse to navigate.
      If application is submitted by mistake, use the "BACK" Button on your browser to return to the application.

- Allow up to 2 weeks to receive a quotation with a fully completed application

GENERAL INFORMATION

Named Insured:		Contact:
Residence Address:		Phone: This isCell Biz Home
City, State, Zip:	State: Zip:	Email:
County:		Need By Date:

POLICY INFORMATION

Current Carrier: Expiration Date: Current Premium:
(Not Agency) State "NONE" if no current coverage.

DRIVER INFORMATION
- We will call for SS#(s) -

NAME	DATE OF BIRTH	SEX	STATUS	DRIVER LICENSE # / STATE LICENSED
1.		Male Female	Married Single	#St
2.		Male Female	Married Single	#St
3.		Male Female	Married Single	#St
4.		Male Female	Married Single	#St

ACCIDENTS & VIOLATIONS - Past 3 Years
Note: Driver Records will be verified by State Reports. Any undisclosed accidents or
violations could result in an increase in premium or cancellation of coverage.

Driver #	Date of Accident / Violation	Description of Accident or Violation (Include MPH over speed limit for speeding violations)

VEHICLE INFORMATION

Year ( _ _ )	Make / Model / Type	V I N (Vehicle Identification #)	Main Driver (List #)	Miles to Work or School	Pleasure Use Only	Compreh. Deductible	Collision Deductible
1.
2.
3.
4.

LIMITS OF INSURANCE

BODILY INJURY LIMITS	Each Person
	Each Accident
TORT OPTION (Choose One)		Full Tort Limited Tort (limits right to sue unless serious injury, small discount applies)
PROPERTY DAMAGE LIMIT	Each Accident
UNINSURED MOTORIST LIMITS	Each Person	Stacked Coverage OR Non-Stacked Coverage
(Underinsured Limit will be same)
FIRST PARTY BENEFITS		Medical Payments: Work Loss: Funeral Expense: Accidental Death:

Towing Reimbursement Coverage: List Vehicle #'s (above) to Request Towing Coverage:

Rental Reimbursement Coverage: List Vehicle #'s (above) to Request Rental Reimbursement Coverage:

Lease Gap Coverage: List Vehicle #'s (above) which are Leased:

UNDERWRITING INFORMATION

1. Any drivers license been suspended?	Y N
2. Any other Losses / Claims not shown above?	Y N
3. Any driver have physical or mental impairment?	Y N
4. Do you currently have an auto policy in force?	Y N
5. Have you had continuous auto coverage for the last 6 months?	Y N
6. Have you had continuous auto coverage for the past year?	Y N
7. Any coverage declined cancelled or non-renewed during the last 3 years?	Y N

PLEASE EXPLAIN "Y" (Yes) answers above:

ADDITIONAL COVERAGES / COMMENTS / INFORMATION

The above information is correct to the best of my knowledge. Check: Initials:

   WOULD ALSO LIKE A QUOTE FOR:
   HOMEOWNERS - Please complete HOME OWNERS Quote Form on our website and "Submit"
   Companies can apply credits for Home Owners & Personal Auto Policies combined.

QUESTIONS / HELP	Contact Pittsburgh Office
Phone:	(412) 271-8888 8:30am-4:30pm Mon-Fri
Fax:	(412) 271-8898
Email:	insurance@thompsongusic.com