Please provide the following contact information:
Name:
Street Address:
Address (cont.):
City:
State:
Zip Code:
Business Phone:
Home Phone:
FAX:
E-mail:
How should we contact you?

Coverages and limits:
Do you currently have coverage:	Yes No
Bodily injury and property damage
Medical payments
Comprehensive deductible
Collision deductible
Towing and labor	Yes No
Rental Reimbursement	Yes No

ll Licensed Drivers in Household

Driver #1
Driver's Name		Relation to You	Date of Birth	Sex Male Female
Marital Status Married Single	Student with 'A' or 'B' avg? Yes No	Date First Licensed (ie: 01/77)	Driver's Training Yes No	Smoker? Yes No

Driver #2
Driver's Name		Relation to You	Date of Birth	Sex Male Female
Marital Status Married Single	Student with 'A' or 'B' avg? Yes No	Date First Licensed (ie: 01/77)	Driver's Training Yes No	Smoker? Yes No

Driver #3
Driver's Name		Relation to You	Date of Birth	Sex Male Female
Marital Status Married Single	Student with 'A' or 'B' avg? Yes No	Date First Licensed (ie: 01/77)	Driver's Training Yes No	Smoker? Yes No

Vehicle Information

Car #1
Year	Make (Ford, Dodge, etc)	Model (Mustang, Grand Am, etc)	Sub-model (GT, LE, etc)
Vehicle Identification Number (VIN)		No. of Cyls.	Body Style (sedan, wagon, etc)
If driven to work or school (enter "0" if not driven to work or school)
Miles One Way	Days per Week	Avg. Annual Mileage	Is car used on job other than commuting? Yes No
Check all that apply:
Air Bags	Single Dual None	Anti-Theft Devices	Factory Other None
Automatic Seat Belts	Yes No	Anti-Lock Brakes	Yes No
Percent Use of Car (Must equal 100%)
Driver #1 %	Driver #2 %	Driver #3 %	Total = 100%

Car #2
Year	Make (Ford, Dodge, etc)	Model (Mustang, Grand Am, etc)	Sub-model (GT, LE, etc)
Vehicle Identification Number (VIN)		No. of Cyls.	Body Style (sedan, wagon, etc)
If driven to work or school (enter "0" if not driven to work or school)
Miles One Way	Days per Week	Avg. Annual Mileage	Is car used on job other than commuting? Yes No
Check all that apply:
Air Bags	Single Dual None	Anti-Theft Devices	Factory Other None
Automatic Seat Belts	Yes No	Anti-Lock Brakes	Yes No
Percent Use of Car (Must equal 100%)
Driver #1 %	Driver #2 %	Driver #3 %	Total = 100%

Car #3
Year	Make (Ford, Dodge, etc)	Model (Mustang, Grand Am, etc)	Sub-model (GT, LE, etc)
Vehicle Identification Number (VIN)		No. of Cyls.	Body Style (sedan, wagon, etc)
If driven to work or school (enter "0" if not driven to work or school)
Miles One Way	Days per Week	Avg. Annual Mileage	Is car used on job other than commuting? Yes No
Check all that apply:
Air Bags	Single Dual None	Anti-Theft Devices	Factory Other None
Automatic Seat Belts	Yes No	Anti-Lock Brakes	Yes No
Percent Use of Car (Must equal 100%)
Driver #1 %	Driver #2 %	Driver #3 %	Total = 100%

Please list your driving record, accidents, convictions & violations for the last 5 years.

Now, click on the submit button to send in your request for a quote on Automobile insurance.

Slawsby Insurance Agency
A Minuteman Service Company
phone:800-258-1776
fax: (603) 882-1843
e-mail: info@minutemangroup.com