First Name  

Last Name  

Address  

City  

County  

State   KY         Zip Code  

Home Phone Number  

Work Phone Number  

E-Mail  

Do you currently hold auto insurance?   Yes No

If yes, what company are you currently with?  

How many vehicles do you have?   1 2 3 4

VEHICLE 1

Year   Make

Model  

VIN    

Airbags   No Air Bags Driver Side Aigbag Only Driver and passenger side airbag   ABS   Yes No

Usage   Pleasure To work less than 3 miles To work greater than 3 miles Business Farm  

VEHICLE 2

Year   Make

Model  

VIN     

Airbags   No air bags Driver side airbag only Driver and passenger side airbag   ABS   Yes No

Usage   Pleasure To work less than 3 miles To work greater than 3 miles Business Farm

VEHICLE 3

Year    Make

Model  

VIN    

Airbags   No air bags Driver side airbag only Driver and passenger side airbag   ABS   Yes No

Usage   Pleasure To work less than 3 miles To work greater than 3 miles Business Farm

VEHICLE 4

Year   Make

Model  

VIN     

Airbags   No air bags Driver side airbag only Driver and passenger side airbag   ABS   Yes No

Usage   Pleasure To work less than 3 miles To work greater than 3 miles Business Farm

LIABILITY

BODILY INJURY AND PROPERTY DAMAGE

BODILY INJURY LIABILITY

Pays for damages that involve bodily injury to others for which you become responsible under law.

PROPERTY DAMAGE LIABILITY

PLEASE SELECT YOUR BODILY INJURY AND PROPERTY DAMAGE LIABILITY LIMITS BELOW.  THE FIRST VALUE IS THE BODILY INJURY LIMIT PER PERSON.  THE SECOND VALUE IS THE BODILY INJURY LIMIT PER ACCIDENT OR OCCURRENCE.  THE THIRD VALUE IS THE PROPERTY DAMAGE LIABILITY LIMIT.

Bodily injury/property damage liability   MUST SELECT ONE $25,000/$50,000/$10,000 $25,000/$50,000/$25,000 $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$250,000 $300,000/$300,000/$300,000 $500,000/$500,000/$500,000

PERSONAL INJURY PROTECTION / KY NO FAULT

Personal injury protection covers you, your family, and your passengers, regardless of fault, if they are injured in an auto accident.

                                    PIP   BASIC $10,000 $20,000 $30,000 $40,000 $50,000

Uninsured Motorist            

This coverage allows you to recover bodily injury damages due to an accident where the other party does not have insurance, and is found legally liable.

Uninsured Motorist   Rejected $25,000/$50,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $300,000/$300,000 $500,000/$500,000  

NOTE: Uninsured and underinsured motorist coverage limits can not exceed bodily injury limits selected above

Underinsured Motorist

This coverage allows you to recover bodily injury damages due to an accident where the other party is found legally liable and does not have adequate liability limits.

NOTE: You must select uninsured motorist in order to get underinsured motorist

Underinsured Motorist   REJECTED $25,000/$50,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $300,000/$300,000 $500,000/$500,000

Collision coverage protects against the loss or damage to your vehicle as the result of a collision. It is subject to a deductible.

Please chose deductible for each vehicle
      

VEHICLE 1   No Coverage $250 Deductible $500 Deductible $1,000 Deductible

VEHICLE 2   No Coverage $250 Deductible $500 Deductible $1,000 Deductible

Other than collision coverage protects you against loss or damage to your vehicle due to fire, theft, vandalism and several other perils. It is subject to a deductible

Please chose deductible for each vehicle

VEHICLE 1   No Coverage No Deductible $250 Deductible $500 Deductible $1,000 Deductible

VEHICLE 2   No Coverage No Deductible $250 Deductible $500 Deductible $1,000 Deductible

VEHICLE 3   No Coverage No Deductible $250 Deductible $500 Deductible $1,000 Deductible

VEHICLE 4   No Coverage No Deductible $250 Deductible $500 Deductible $1,000 Deductible

NOTE: You must have selected collision and other than collision in order to get towing and labor.

VEHICLE 1   No Coverage Yes

VEHICLE 2   No Coverage Yes

VEHICLE 3   No Coverage Yes

VEHICLE 4   No Coverage Yes

NOTE: You must have selected collision and other than collision in order to get rental reimbursement .  

VEHICLE 1   No Coverage Yes No

VEHICLE 2   No Coverage Yes No

VEHICLE 3   No Coverage Yes No

VEHICLE 4   No Coverage Yes No  

DRIVER 1

Name           Relation   Applicant Spouse Daughter Son

Birthdate  

Sex   Male Female   Marital Status   Married Single Divorced Seperated

Does this driver have a Kentucky drivers license?   Yes No

License Number  

DRIVER 2

Name     Relation   Applicant Spouse Daughter Son

Birthdate  

Sex   Male Female    Marital Status   Married Single Divorced Seperated

Does this driver have a Kentucky drivers license?   Yes No

License Number  

DRIVER 3

Name    Relation   Applicant Spouse Daughter Son

Birthdate  

Sex   Male Female   Marital Status   Married Single Divorced Seperated

Does this driver have a Kentucky drivers license?   Yes No

License Number  

DRIVER 4

Name      Relation   Applicant Spouse Daughter Son

Birthdate  

Sex   Male Female   Martial Statue Married Single Divorced Seperated

Does this driver have a Kentucky drivers license?   Yes No

License Number  

Has any driver ever been convicted of any moving traffic violation?  

DRIVER 1   Yes No                                    DRIVER 2   Yes No

DRIVER 3   Yes No                                    DRIVER 4   Yes No

If yes describe below including date and occurrence:

Has any driver been involved in any accidents regardless of fault, or made any claims to his or her insurance company for any reason in the past 5 years?

DRIVER 1   Yes No                                     DRIVER 2   Yes No

DRIVER 3   Yes No                                     DRIVER 4   Yes No

If yes provide details below including dates and what happened

Has any driver ever had a license suspension or revocation?

DRIVER 1   Yes No                                     DRIVER 2   Yes No

DRIVER 3   Yes No                                     DRIVER 4   Yes No

How did you hear about us?   Search Engine Yellow Pages Television Friend Other

Did you know that if you insure you auto and your home with the same company you qualify for a multi policy discount.

If you would like a FREE quote on your homeowners or renters insurance check the approate box below and AFTER you submit this form click on the approate link on the next page.

Yes, I will be submitting a free Homeowner's Quote inquery

Yes, I will be submitting a free Renter's Quote inquery