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Section 1 Personal Information

Full Name
Married Yes No
Spouse's Full Name
Address
E-mail Address
Daytime Phone Evening Phone Cell Phone
Preferred Contact Method
Drivers License Number
Do You Have Medical Insurance? Yes No
Name of Your Current Medical Carrier
Name of Your Current Employer
Employer Address
Have You Had Auto Insurance Coverage for the Past 6 Months? Yes No
Group Discounts? Check All That May Apply
Other Possible Discounts
Number of Driving Family Members
Number of Vehicles
How Many Accidents in the Last 3 Years?
How Many Were They at Fault?
How Many Tickets in the Last 3 Years?

End of Section 1
(Please Complete Section(s) 2/3/4)

Section 2 Family Members


 This section contains all the information about your family members. Keep in mind that it is important to provide accurate information in this section since it can have an effect on the quote. If you are the only person on your policy then you may skip this section.

 

Family Member 1 (Spouse if Married)
Full Name
Date of Birth
Drivers License Number
How Many Accidents Were in the Last 3 Years?
How Many Accidents Were At Fault?
How Many Tickets in the Last 3 Years?

Family Member 2
Full Name
Date of Birth
Drivers License Number
How Many Accidents in the Last 3 Years?
How Many Were They at Fault?
How Many Tickets in the Last 3 Years?

Family Member 3
Full Name
Date of Birth
Drivers License Number
How Many Accidents in the Last 3 Years?
How Many Were They at Fault?
How Many Tickets in the Last 3 Years?

Family Member 4

Full Name
Date of Birth
Drivers License Number
How Many Accidents in the Last 3 Years?
How Many Were They at Fault?
How Many Tickets in the Last 3 Years?

Family Member 5
Full Name
Date of Birth
Drivers License Number
How Many Accidents in the Last 3 Years?
How Many Were They at Fault?
How Many Tickets in the Last 3 Years?

Family Member 6
Full Name
Date of Birth
Drivers License Number
How Many Accidents in the Last 3 Years?
How Many Were They at Fault?
How Many Tickets in the Last 3 Years?

End of Section 2
(Please Complete Section(s) 3/4)

Section 3 Vehicle Information


This section contains all the information for the vehicles you own. This includes features on your car which may result in a lower premium. Please take the time to accurately fill in as much as possible. For the "usage" selection the difference between "work" and "business" is that

Vehicle 1 Information
Name on the Title Odometer Reading
Make Year
Model Vin Number
Usage Alarm: Yes No
Air Bag: Yes No ABS System: Yes No
Who Drives This Vehicle (Separate the Names With a Comma).

Vehicle 2
Name on the Title Odometer Reading
Make Year
Model Vin Number
Usage Alarm: Yes No
Air Bag: Yes No ABS System: Yes No
Who Drives This Vehicle (Separate the Names With a Comma).

Vehicle 3
Name on the Title Odometer Reading
Make Year
Model Vin Number
Usage Alarm: Yes No
Air Bag: Yes No ABS System: Yes No
Who Drives This Vehicle (Separate the Names With a Comma).

Vehicle 4
Name on the Title Odometer Reading
Make Year
Model Vin Number
Usage Alarm: Yes No
Air Bag: Yes No ABS System: Yes No
Who Drives This Vehicle (Separate the Names With a Comma).

Vehicle 5
Name on the Title Odometer Reading
Make Year
Model Vin Number
Usage Alarm: Yes No
Air Bag: Yes No ABS System: Yes No
Who Drives This Vehicle (Separate the Names With a Comma).

Vehicle 6
Name on the Title Odometer Reading
Make Year
Model Vin Number
Usage Alarm: Yes No
Air Bag: Yes No ABS System: Yes No
Who Drives This Vehicle (Separate the Names With a Comma).

End of Section 3
(Please Complete Section 4/4)

Section 4 Coverage Information


In this section you can decide what types of coverage you'd like to apply to each vehicle. Please use the vehicle numbers from the previous section when completing this form.

Not Sure About Which Coverage? Check Out Our FAQ!
(Note: This will open in a seperate window so you don't lose all of your information)

General Coverage Information
Bodily Injury/Property Damage
PIP
Deductible on Medical
Medical Carrier
Disability Coverage
Disability Carrier

Vehicle 1 Coverages
No Fault Yes No ETS Yes No
Rental Yes No Collision Coverage Type Regular Broad
Comp Deductible Collision Deductible

Vehicle 2 Coverages
No Fault: Yes No ETS: Yes No
Rental: Yes No Collision Coverage Type: Regular Broad
Comp Deductible Collision Deductible

Vehicle 3 Coverages
No Fault: Yes No ETS: Yes No
Rental Yes No Collision Coverage Type: Regular Broad
Comp Deductible Collision Deductible

Vehicle 4 Coverages
No Fault: Yes No ETS: Yes No
Rental: Yes No Collision Coverage Type: Regular Broad
Comp Deductible Collision Deductible

Vehicle 5 Coverages
No Fault: Yes No ETS: Yes No
Rental: Yes No Collision Coverage Type: Regular Broad
Comp Deductible Collision Deductible

Vehicle 6 Coverages
No Fault Yes No ETS Yes No
Rental Yes No Collision Coverage Type Regular Broad
Comp Deductible Collision Deductible

 

End of Section 4
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Hartland Michigan Auto Insurance