Contact Information Your Name: *   Address: *   City: *   State: *   Zip: *   Primary Residence: * -Select- Rent Own Home Own Condo Own Mobile Home Live With Parent Other   Daytime Phone: *   E-Mail: *   Are you a member of any group? -Select- AARP Credit Union MEA College Alumni Farm Organization Condo Association Neighborhood Assoc. Lions Club Rotary VFW Other         Current Auto Insurance: Do you have current auto insurance? * -Select- Yes No, Recently lapsed/cancelled No, Insured's first car No, FIX THIS No, Other reason   Current auto insurance company? None AAA Allstate Auto Owners Bristol West Citizens Farm Bureau Farmers Insurance Fremont Ins. Co. Michigan Ins. Co. Pioneer Mutual Progressive State Farm Titan Other   Expiration date of current policy:   Current liability limits: -Select- 20/40 50/100 100/300 250/500 500/500 1million         Drivers in your household: How many licensed drivers in your household? 1234 or more

Please list all Household Members (Anyone using your address as their home address)   Name Date of Birth Driver's License Occupation Health Insurance Co Marital Status 1 None Medicare Medicaid Blue Cross Blue Shield Priority Health Other Single Married 2 None Medicare Medicaid Blue Cross Blue Shield Priority Health Other Single Married 3 None Medicare Medicaid Blue Cross Blue Shield Priority Health Other Single Married 4 None Medicare Medicaid Blue Cross Blue Shield Priority Health Other Single Married

About your Vehicles: How many licensed vehicles are in your household? 123 or more         Vehicle 1: Driver: Year: Make: Model: VIN: Primary use: Pleasure Business To Work/School Farm Use Only Miles one way to work/school: 0-3 Miles 3-15 Miles 15 and Over Annual Mileage: 0-3,000 Miles 3,000 and Over Vehicle 2: Driver: Year: Make: Model: VIN: Primary use: Pleasure Business To Work/School Farm Use Only Miles one way to work/school: 0-3 Miles 3-15 Miles 15 and Over Annual Mileage: 0-3,000 Miles 3,000 and Over Vehicle 3: Driver: Year: Make: Model: VIN: Primary use: Pleasure Business To Work/School Farm Use Only Miles one way to work/school: 0-3 Miles 3-15 Miles 15 and Over Annual Mileage: 0-3,000 Miles 3,000 and Over Vehicle 4: Driver: Year: Make: Model: VIN: Primary use: Pleasure Business To Work/School Farm Use Only Miles one way to work/school: 0-3 Miles 3-15 Miles 15 and Over Annual Mileage: 0-3,000 Miles 3,000 and Over

Desired coverage and limits: (Click the for an explanation of these coverages) Vehicle Collision Options Collision Deductible Comprehensive Deductible Car Rental (per day) Towing Vehicle 1: None Broad Basic Limited None $250 $500 $1000 None $0 $50 $100 $250 $500 None $20 $30 $40 None Yes No Vehicle 2: None Broad Basic Limited None $250 $500 $1000 None $0 $50 $100 $250 $500 None $20 $30 $40 None Yes No Vehicle 3: None Broad Basic Limited None $250 $500 $1000 None $0 $50 $100 $250 $500 None $20 $30 $40 None Yes No Vehicle 4: None Broad Basic Limited None $250 $500 $1000 None $0 $50 $100 $250 $500 None $20 $30 $40 None Yes No

Have you or any of the members of your household listed above, had any tickets, accidents or auto losses in the last 5 years? If yes, please describe in detail including when, where, if a ticket was issued and how much was paid out on the claim.

Have you or any of the members of your household listed above, ever had a DUI or Reckless Driving ticket? If yes, please describe who and when it happened.

Additional Comments

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