McAlpin Agency, Inc. Snowmobile Insurance Quote Request Form for Minnesota MN Allied Progressive Foremost

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

General Information

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

Residence Information

Primary Residence
Months at Address

Current Snowmobile Insurance Information

Current Insurance Co.	Expiration Date

Operator Information (please list all Operators)

Driver #1
Name	Birth date	Sex	Marital Status	Years Experience

Social Security #		Driver License #
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comment

Driver #2
Name	Birth date	Sex	Marital Status	Years Experience

Social Security #		Driver License #
Number of Accidents (Last 5 Years)		Comment on Accidents (Date, Fault, Amount)
Number of Violations (Last 5 Years)		Comment on Violations (Date, Violation Type)
Comment

Percentage of Use

	Driver 1.	Driver 2.
Snowmobile 1.
Snowmobile 2.

Snowmobile Information

Snowmobile Unit 1.

Year

Make

Model

Number of CC's

Years Owned

Garaged

Value

Describe Any Accessories/Special Equipment Including Cost When New

Yes

Snowmobile Unit 2.

Year

Make

Model

Number of CC's

Years Owned

Garaged

Value

Describe Any Accessories/Special Equipment Including Cost When New

Yes

Trailer Information

Year	Make	Model	Value

Coverage's

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

Medical Expense Coverage. If you and your passengers are injured in an watercraft accident, this coverage pays your medical expenses.
Medical Expense		Comment

Uninsured and Underinsured Operator Coverage. Pays bodily injury claims if you or your passengers are injured by a negligent uninsured operator, hit-and-run operator or a negligent operator without adequate insurance.
Uninsured/Underinsured Operator		Comment

Comprehensive Coverage. Pays for damage to your snowmobile caused by theft, fire, windstorm, vandalism and many other non-collision occurrences. Collision Coverage. If your snowmobile collides with another vehicle or object, this coverage pays to repair your snowmobile.
	Snowmobile 1.	Snowmobile 2.	Trailer
Comprehensive Deductible
Collision Deductible

Comments

Last modified: August 04, 2008