PERSONAL INFORMATION Your name*          E-Mail address*     Phone numbers     Daytime*: Evening: Fax: How would you prefer to be contacted* regarding your quote?     Phone Fax Mail   E-mail If you would prefer to be contacted by phone, please let us know the best time to call.     Address     City     State*     Zip code     Do you currently own your home, or rent?     Own Rent Driver's license number     Social security number

VEHICLE #2 INFORMATION Year Make Model Vehicle ID# (VIN) Primary driver: Annual mileage: Is the vehicle driven to school or work?  If driven to school or work, how many days per month? If driven to school or work, how many miles one way? Select One Driver #1 Driver #2 Driver #3 Driver #4    Yes No Miles Is the vehicle in any way modified or customized? Is there any existing damage to the vehicle? Yes No Yes No If vehicle is kept at an address other than that listed above, please indicate below: Address: City:    State:    Zip:

DRIVER INFORMATION   Name Relationship to applicant Sex Marital status Driver's age Which vehicle does he/she drive? Percent use Driver #1 Select One Self Spouse Child Parent Other Male Female Married Single Select One Vehicle #1 Vehicle #2 Driver #2 Select One Self Spouse Child Parent Other Male Female Married Single Select One Vehicle #1 Vehicle #2 Driver #3 Select One Self Spouse Child Parent Other Male Female Married Single Select One Vehicle #1 Vehicle #2 Driver #4 Select One Self Spouse Child Parent Other Male Female Married Single Select One Vehicle #1 Vehicle #2

DRIVER HISTORY Are you currently insured? : Yes  No How long have you had auto insurance coverage (Years and Months): What is the name of your insurance company? Did you take Driver Training? If yes – Do you have the Certificate? If a Student 25 years or younger, do you have a GPA 3.0 or Higher?  Yes  No What month and Year were you first licensed?(MM/YYYY)  Have you or any other driver in your household: Had a ticket in the last 3 years? Had a license suspended or revoked in the last 6 years?   Made any claims in the last 5 years? Yes No Yes No   Yes No         If you answered yes to any of the above questions, please explain:

COVERAGE OPTIONS Bodily Injury/ Property Damage: Select One $15/30/5 $25/50/10 $25/50/25 $100/300/50 $100/300/100 $250/500/100 Thousand Dollars Underinsured motorist-bodily injury: Select One $15/30/5 $25/50/10 $25/50/25 $100/300/50 $100/300/100 $250/500/100 Thousand Dollars Underinsured motorist-property damage: Select One None $25,000 $50,000 $100,000 $250,000 Dollars (NEW JERSEY RESIDENTS ONLY) Medical-personal injury protection: Select One None $10,000 $25,000 $35,000 Dollars

COVERAGE DEDUCTIBLES   Comprehensive deductible Collision deductible Towing coverage deductible Vehicle #1 Select One $250 $500 $1000 $2500 Select One $250 $500 $1000 $2500 Select One Not interested $50 $100 $200 Vehicle #2 Select One $250 $500 $1000 $2500 Select One $250 $500 $1000 $2500 Select One Not interested $50 $100 $200 Do you have AAA or RoadSide Assistance?

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?