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Michael W. Smith Agency

Revised:

May 06, 2015

Auto / Car

 763-535-7293

 

 

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Information

 

Please complete the form carefully.

If you have credit problems, tell me about it in the comments box.

The first 8 digits of the VIN are used to determine the make and model of your vehicle.

 

Antique Car InsuranceTruck InsuranceHigh value and sports car 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 auto insurance products. Please complete this form as accurately as possible. Auto insurance rates are subject to change.

Representing the following automobile insurance companies: AAA, Allied, Auto Owners, Dairyland, Encompass, Hagerty, Kemper, Progressive & Western National.

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General Information

Name
Street
City, State ZIP                   
Phone
E-mail
FAX

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 Insurance Company
Expiration Date
Months With Company
Current Bodily Injury Limit

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Driver Information (please list all drivers)

Driver #1
Name Birthdate Sex Marital Status
Social Security # Drivers License #  

Level of Education

 

Defensive Driver Class
(age 55 and older)
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

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Driver #2

Name Birthdate Sex Marital Status
Social Security # Drivers License #

Level of Education

 

Defensive Driver Class
(age 55 and older)
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

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Driver #3
Name Birthdate Sex Marital Status
Social Security # Drivers License #

Level of Education

 

Defensive Driver Class
(age 55 and older)
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

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Driver #4
Name Birthdate Sex Marital Status
Social Security # Drivers License #

Level of Education

 

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

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Vehicle Information

Veh #1 Year Make Model VIN #
 
Air Bags Anti-Lock Brakes Alarm System Usage
Yes No Yes No
Comments

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Veh #2 Year Make Model VIN #
Air Bags Anti-Lock Brakes Alarm System Usage
Yes No Yes No
Comments

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Veh #3 Year Make Model VIN #
Air Bags Anti-Lock Brakes Alarm System Usage
Yes No Yes No
Comments

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Veh #4 Year Make Model VIN #
Air Bags Anti-Lock Brakes Alarm System Usage
Yes No Yes No
Comments

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Percentage of Use

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

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Coverage's

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

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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

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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

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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

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Comments

 

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Number of Hits Since August 15, 1998

 

 

 

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Copyright 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 Michael W. Smith Agency