Michael W. Smith Agency

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Auto Insurance

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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.

General Information

Name
Street
City, State ZIP   
Phone
E-mail
FAX

Residence Information

Primary Residence
Months at Address

Current Automobile Insurance Information

Current Company
Expiration Date
Months With Company

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Driver Information (please list all drivers)

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

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Driver #2

Name Birthdate Sex Marital Status
Social Security # Drivers 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)

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

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Vehicle Information

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

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

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

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Percentage of Use

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

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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

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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.

Comprehensive Deductible

Collision Deductible

Full Glass

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

Send mail to mwsmith@visi.com with questions or comments about this web site.

Since 1978
Michael W. Smith Agency

Copyright © 2000 Michael W. Smith Agency
Last modified: April 06, 2008