Quote Prepared For:

Name:                   

Address:                  

City:                          State:             Zip:           

Home Phone            Work Phone:          Fax #: 

E-Mail Address:

Current Policy Renewal Date: (mm/dd/yyyy)

Driver List:
Driver #1: (required)
Name:                        DOB:          (mm/dd/yyyy)

License Number:           State:

Tickets within past five years?  Yes    No    If yes, how many?

Accidents within past five years?  Yes    No   If yes, how many?

Driver #2: (if applicable)
Name:   DOB: (mm/dd/yyyy)

License Number:    State:

Tickets within past five years?  Yes   No    If yes, how many?

Accidents within past five years?  Yes   No   If yes, how many?

Driver #3: (if applicable)
Name:   DOB: (mm/dd/yyyy)

License Number:    State:

Tickets within past five years?  Yes   No    If yes, how many?

Accidents within past five years?  Yes   No   If yes, how many?

Driver #4: (if applicable)
Name:   DOB: (mm/dd/yyyy)

License Number:    State:

Tickets within past five years?  Yes   No    If yes, how many?

Accidents within past five years?  Yes   No   If yes, how many?

Driver #5: (if applicable)
Name:   DOB: (mm/dd/yyyy)

Tickets within past five years?  Yes   No    If yes, how many?

Accidents within past five years?  Yes   No   If yes, how many?

Please explain ALL tickets or accidents for EACH driver:
(List Driver Name along with Number Miles Over Speed Limit for each
ticket and/or Amount Paid By Your Insurance Company for each accident)

Vehicle List:
Vehicle #1: (required)
Year:                        Make:                        Model:                       

VIN:   Use of Vehicle:                      Select Work (less than 5 miles) Work (5-9 miles) Work (10-15 miles) Work (more than 15 miles) Business Pleasure

Comprehensive Deductible:                      Select $50 $100 $250 $500   Collision Deductible:                      Select $100 $200 $250 $500 $1000

Rental Car? Yes    No   If yes, choose coverage: Select $15/day - $450 maximum $30/day - $900 maximum

Towing Coverage? Yes    No   If yes, select option: Select $25 $50

Air Bags? Yes    No   If yes, how many? Select one two or more

Anti-Theft Devices? Yes  No   If yes, what type? Select Active (Activated Manually) Passive (Activated Automatically)

Anti-Lock Brakes? Yes    No   If yes, select deployment: Select Front Only Rear Only Front and Rear

Burglar Alarm? Yes    No

Vehicle #2: (if applicable)
Year:   Make:   Model:

VIN:   Use of Vehicle: Select Work (less than 5 miles) Work (5-9 miles) Work (10-15 miles) Work (more than 15 miles) Business Pleasure

Comprehensive Deductible: Select $50 $100 $250 $500   Collision Deductible: Select $100 $200 $250 $500 $1000

Rental Car? Yes   No   If yes, choose coverage: Select $15/day - $450 maximum $30/day - $900 maximum

Towing Coverage? Yes   No   If yes, select option: Select $25 $50

Air Bags? Yes   No   If yes, how many? Select one two or more

Anti-Theft Devices? Yes No   If yes, what type? Select Active (Activated Manually) Passive (Activated Automatically)

Anti-Lock Brakes? Yes   No   If yes, select deployment: Select Front Only Rear Only Front and Rear

Burglar Alarm? Yes   No

Vehicle #3: (if applicable)
Year:   Make:   Model:

VIN:   Use of Vehicle: Select Work (less than 5 miles) Work (5-9 miles) Work (10-15 miles) Work (more than 15 miles) Business Pleasure

Comprehensive Deductible: Select $50 $100 $250 $500   Collision Deductible: Select $100 $200 $250 $500 $1000

Rental Car? Yes   No   If yes, choose coverage: Select $15/day - $450 maximum $30/day - $900 maximum

Towing Coverage? Yes   No   If yes, select option: Select $25 $50

Air Bags? Yes   No   If yes, how many? Select one two or more

Anti-Theft Devices? Yes No   If yes, what type? Select Active (Activated Manually) Passive (Activated Automatically)

Anti-Lock Brakes? Yes   No   If yes, select deployment: Select Front Only Rear Only Front and Rear

Burglar Alarm? Yes   No

Vehicle #4: (if applicable)
Year:   Make:   Model:

VIN:   Use of Vehicle: Select Work (less than 5 miles) Work (5-9 miles) Work (10-15 miles) Work (more than 15 miles) Business Pleasure

Comprehensive Deductible: Select $50 $100 $250 $500   Collision Deductible: Select $100 $200 $250 $500 $1000

Rental Car? Yes   No   If yes, choose coverage: Select $15/day - $450 maximum $30/day - $900 maximum

Towing Coverage? Yes   No   If yes, select option: Select $25 $50

Air Bags? Yes   No   If yes, how many? Select one two or more

Anti-Theft Devices? Yes No   If yes, what type? Select Active (Activated Manually) Passive (Activated Automatically)

Anti-Lock Brakes? Yes   No   If yes, select deployment: Select Front Only Rear Only Front and Rear

Burglar Alarm? Yes   No

Liability/Medical Limits:
Bodily Injury Liability Limits:                      Select $100,000/person - $300,000/accident $250,000/person - $500,000/accident $300,000/person - $300,000/accident $500,000/person - $500,000/accident

Property Damage Liability Limit:                      Select $50,000 $100,000 $250,000 $500,000

Uninsured/Underinsured Bodily Injury Liability Limits:                      Select None $100,000/person - $300,000/accident $250,000/person - $500,000/accident $300,000/person - $300,000/accident $500,000/person - $500,000/accident

Uninsured/Underinsured Property Damage Liability Limit:                      Select None $50,000 $100,000 $250,000 $500,000

Medical Payment Amount:                      Select None $1,000 $2,000 $5,000 $10,000 $25,000 $50,000

Comments:
Please list any preference you may have regarding how and/or when we
may contact you with your Quote - or any additional comments:

"With this information, I understand that Summit Insurance will be able to pull my Motor Vehicle Report in order to give me a more accurate quote."