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  Welcome!
Attention:
Effective Date:
Your Name:
Your Mailing Address: Street

City & State                               Zip
  
E-mail Address:
Daytime Phone #:
Choose One: Please call me with quote premium.
Please send quote via e-mail.
Current coverage: Company:                         Expiration Date:
 


Liability Limits and Coverages:
Please select the coverages and limits that are to apply to your vehicles.
Bodily Injury
Property Damage
Medical Payments
Uninsured Motorists


Uninsured Motorists Property Damage
Enter additional information/comments here:


Your Vehicles:  
If you have more than four vehicles, please call (330-494-8400) our office for a quote.

Vehicle 1
Year    Make and model:
 
VIN (if known):

Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
Towing and Labor
Rental Reimbursement
Loan Lease Gap
Vehicle 2
Year    Make and model:
 
VIN (if known):

Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
Towing and Labor
Rental Reimbursement
Loan Lease Gap
Vehicle 3
Year    Make and model:
 
VIN (if known):

Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
Towing and Labor
Rental Reimbursement
Loan Lease Gap
Vehicle 4
Year    Make and model:
 
VIN (if known):

Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
Towing and Labor
Rental Reimbursement
Loan Lease Gap


Driver Information:  
If there are more than four drivers, please call (330-494-8400) our office for a quote.

Driver 1:
Name:

DOB:         Sex:      Marital Status
        
Driver 1 Occupation:

Social Security No:   -or-   Drivers License No:
  
Has Driver 1 had any accidents or violations
in the past 3 years?  If yes, please explain below:

Good Student Discount (3.0 ave. or better)
100 Miles" value="Yes"> At School over 100 miles away.

Driver 2:
Name:

DOB:         Sex:      Marital Status
        
Driver 1 Occupation:

Social Security No:   -or-   Drivers License No:
  
Has Driver 1 had any accidents or violations
in the past 3 years?  If yes, please explain below:

Good Student Discount (3.0 ave. or better)
100 Miles" value="Yes"> At School over 100 miles away.

Driver 3:
Name:

DOB:         Sex:      Marital Status
        
Driver 1 Occupation:

Social Security No:   -or-   Drivers License No:
  
Has Driver 1 had any accidents or violations
in the past 3 years?  If yes, please explain below:

Good Student Discount (3.0 ave. or better)
100 Miles" value="Yes"> At School over 100 miles away.

Driver 4:
Name:

DOB:         Sex:      Marital Status
        
Driver 1 Occupation:

Social Security No:   -or-   Drivers License No:
  
Has Driver 1 had any accidents or violations
in the past 3 years?  If yes, please explain below:

Good Student Discount (3.0 ave. or better)
100 Miles" value="Yes"> At School over 100 miles away.


Please use the box below to enter any additional information you feel should be considered:
        

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