Auto Insurance Form

Please complete as much of this form as possible.
Full Name*	A value is required.
Birth Date*	- mm/dd/yyyy A value is required.Invalid format.
Social Security Number*	Your social security number can be submitted over the phone by calling 570-226-4571 and asking for a Personal Agent.
Spouse/Partner Full Name
Birth Date	- mm/dd/yyyy Invalid format.
Social Security Number	Your social security number can be submitted over the phone by calling 570-226-4571 and asking for a Personal Agent.
Email Address*
Additional Email Address
Home Phone*	A value is required.
Work Phone
Resident Address*	A value is required.

Any auto claims in the last 5 yrs	Yes No
If yes, date & description

Driver Information
Drivers 1 information state issued, license number
Driver 2 information state issued, license number
Driver 3 information state issued, license number
Driver 4 information state issued, license number

Vehicle 1 Information (Required)
Who is the primary driver of this auto?
Do you own or lease this auto?	Yes No
If leased, please enter lessor contact information (name, address, city, state, zip, phone)

Year*	A value is required.
Make*	A value is required.
Model*	A value is required.
Vin Number*	A value is required.
Comprehensive Deductibles	$100 $250 $500 $1000
Collision Deductibles	$100 $250 $500 $1000
Towing and Labor	$25 $50 $75
Rental Car	$30 $40 $50

Vehicle 2 Information (If Applicable)
Who is the primary driver of this auto?
Do you own or lease this auto?	Yes No
If leased, please enter lessor contact information (name, address, city, state, zip, phone)

Year
Make
Model
Vin Number

If the following information is not known, please leave blank. Enter Liability information in the next section.
Comprehensive Deductibles	$100 $250 $500 $1000
Collision Deductibles	$100 $250 $500 $1000
Towing and Labor	$25 $50 $75
Rental Car	$30 $40 $50

Vehicle 3 Information (If Applicable)
Who is the primary driver of this auto?
Do you own or lease this auto?	Yes No
If leased, please enter lessor contact information (name, address, city, state, zip, phone)

Year
Make
Model
Vin Number

If the following information is not known, please leave blank. Enter Liability information in the next section.
Comprehensive Deductibles	$100 $250 $500 $1000
Collision Deductibles	$100 $250 $500 $1000
Towing and Labor	$25 $50 $75
Rental Car	$30 $40 $50

Liability Information If the following information is not known, please leave blank.
Liability Limits	100/300/50 250/500/100 Single limit 100,000 Single limit 300,000 Single limit 500,000

How did you hear about us? Provide detail in the field below	Radio Advertisement Friend Camp Search Engine Other
Comments/Notes