Family Info

Your age Spouse's age

Any children? Yes No Do your kids drive? Yes No Age of Drivers?

Present Insurance Company

Has any driver or member of the household:

a) Had any auto insurance refused, cancelled or expired your policy in the past three years? Yes No

b) Been required to file evidence of financial responsibility in the past three years? Yes No

c) Had driver's license revoked or suspended in the past three years? Yes No

d) Received a ticket for speeding or any other vehicle code violation within the past three years? Yes No

e)Been arrested for ANY reason? Yes No

f) Has a physical or mental impairment or disability or other medical infirmity? Yes No

g) Had any comprehensive losses (hit a deer, fire, glass breakage, theft, etc.) or losses involving your parked vehicle(s) in the past three years? Yes No

h) Been involved in an accident or reported a claim to an insurance company during the past three years? Yes No

List vehicles

Vehicle #1
Make Model Year VIN

Vehicle #2
Make Model Year VIN

Vehicle #3
Make Model Year VIN

Coverage desired ? Liability only Full coverage

How many miles do you drive to work one-way?

How many miles do you drive in a year?

Is any car used in business? Yes No

How much are you currently paying per year for automobile insurance?

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2404 East Lake Road Erie, PA 16511 (814) 459-4380 Fax (814) 459-4583