McAlpin Agency, Inc.

Auto Insurance

This is a request for a Minnesota automobile insurance quote, not a policy application. Submitting this form does not obligate you to purchase any products. Please complete this form as accurately as possible. Auto insurance rates are subject to change.

General Information

Name
Street
City, State ZIP
Phone
E-mail
FAX
Agent Request

Underwriting Information

Primary Residence
Months at Address
Primary Residence Insurance
Do You Have Full Time Use of a Company Provided Car?	Yes No
Are You a Current Member of the Auto Club (AAA)?	Yes No

Current Automobile Insurance Information

Current Company
Expiration Date
Months With Company
Current Bodily Injury Limit

Driver Information (please list all drivers)

Driver #1
Name	Birthdate	Sex	Marital Status

Social Security #		Drivers License #
Defensive Driver Class	YesNo	Good Student (B average or better)	Yes No
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comments

Driver #2
Name	Birthdate	Sex	Marital Status

Social Security #		Drivers License #
Defensive Driver Class	YesNo	Good Student (B average or better)	Yes No
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comments

Driver #3
Name	Birthdate	Sex	Marital Status

Social Security #		Drivers License #
Defensive Driver Class	YesNo	Good Student (B average or better)	Yes No
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comments

Driver #4
Name	Birthdate	Sex	Marital Status

Social Security #		Drivers License #
Defensive Driver Class	YesNo	Good Student (B average or better)	Yes No
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comments

Vehicle Information

Veh #1	Year	Make	Model	VIN #

	Airbags	Anti-Lock Brakes	Alarm System	Usage
		Yes No	Yes No
	Comments

Veh #2	Year	Make	Model	VIN #

	Airbags	Anti-Lock Brakes	Alarm System	Usage
		Yes No	Yes No
	Comments

Veh #3	Year	Make	Model	VIN #

	Airbags	Anti-Lock Brakes	Alarm System	Usage
		Yes No	Yes No
	Comments

Veh #4	Year	Make	Model	VIN #

	Air Bags	Anti-Lock Brakes	Alarm System	Usage
		Yes No	Yes No
	Comments

Percentage Of Use

	Veh. #1	Veh. #2	Veh. #3	Veh. #4
Driver #1:
Driver #2:
Driver #3:
Driver #4:

Coverage

Liability Coverage. (Mandatory) Pays for other people's injuries and damage to their property if you or someone else cause an accident while driving your car. It protects your assets in the event you are held liable for damage to others.
Bodily Injury Liability
Property Damage Liability

Personal Injury Protection (No-Fault Coverage). (Mandatory) If you or passengers in your car are injured in an auto accident, this coverage pays for medical expenses, loss of wages and death benefits.
Personal Injury Protection (medical/economic loss)
Personal Injury Protection Deductible

Uninsured and Underinsured Motorists Coverage. (Mandatory) Pays bodily injury claims if you or your passengers are injured by a negligent uninsured motorist, hit-and-run vehicle or a negligent driver without adequate insurance.
Uninsured/Underinsured Motorist

Comprehensive Coverage. Pays for damage to your car caused by theft, fire, windstorm, glass breakage and many other non-collision occurrences. Collision Coverage. If your car collides with another vehicle or object, this coverage pays to repair your auto.
	Vehicle 1.	Vehicle 2.	Vehicle 3.	Vehicle 4.
Comprehensive Deductible
Collision Deductible
Full Glass	Yes No	Yes No	Yes No	Yes No
Rental Car Coverage (per day / limit)
Towing & Labor

Comments

Last modified: June 01, 2010

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Visitors Since August 15, 2000

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Copyright © 2000 - 2008 Michael W. Smith