Insurance Vehicle Quote

INSURANCE VEHICLE QUOTE

Quote Number:    Date of Quote:    Agent/Producer:

Applicant / Insured Information

Phone:    Email:

Vehicle Information

Primary Use:    Annual Mileage:

Anti-theft / Safety Devices:    Lienholder / Finance Company:

Policy Details and Coverage Options

Policy Type (select desired coverages):

Liability (Bodily Injury & Property Damage)
Collision
Comprehensive
Uninsured / Underinsured Motorist
Medical Payments / Personal Injury Protection
Rental Reimbursement
Roadside Assistance

Liability Limits (per person / per accident / property):    Comprehensive Deductible:    Collision Deductible:

Estimated Annual Premium:    Payment Plan Preferred:

Proposed Policy Period: From to

Additional Coverages / Endorsements

New Vehicle Replacement
GAP Coverage
Rental Reimbursement (If selected, enter limit):

Exclusions and Limitations

This quote is subject to the insurer's standard policy form exclusions, which commonly include but are not limited to: intentional loss or illegal acts by an insured; use of the vehicle for hire without endorsement; operation by an excluded driver; wear and tear or mechanical breakdown; losses occurring outside the territorial limits specified in the policy; and diminution in value not arising from covered physical damage. Any express exclusion in the issued policy supersedes coverages described in this quote.

I acknowledge that the quote is an estimate and that the final policy terms, coverages, exclusions, deductibles and premium are determined by underwriting and by the final policy issued by the insurer. This quote is not a binder of coverage unless a binding confirmation is issued by the insurer and required premium is paid.

Applicant acknowledges receipt of the exclusions summary and understands that exclusions may apply to the coverages requested.

Primary Loss Payee / Beneficiary (if applicable)

Claims / Prior Loss History

Certification, Authorization, and Declarations

By signing below, the applicant certifies that all statements made in this quote request are true and complete to the best of the applicant's knowledge. The applicant understands that any material misrepresentation or omission may be grounds for denial of coverage, cancellation of any issued policy, or rescission of coverage from inception, to the extent permitted by law.

The applicant authorizes the insurer, its representatives and agents to obtain motor vehicle records, claims history, credit or underwriting information, and other consumer reports necessary to evaluate eligibility for coverage and premium rating. The applicant further authorizes release of policy and claims information to lienholders listed above as permitted by the policy.

This document is a quote and summary of proposed coverages. It does not amend, alter or extend any insurance policy. Coverage is effective only as stated in the issued policy documents and upon payment of required premium. Coverage limits, deductibles, endorsements and exclusions will be described in the final policy.

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