logo

logo
509 Sterling Highway, Suite 201
Homer, Alaska 99603
Phone: 907-235-3881
 Fax:     907-235-3882
 

  For Personal Auto Insurance, please complete the information form, and our staff will promptly reply.

Please provide the following contact information:

First Name

Last Name

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Work Phone

Home Phone

FAX

E-mail

URL

Information About Your Car or Pickup

Current Auto Insurance Company (not agency):

Policy Expiration Date (mm/dd/yy):    Term: 6 mos.   1 yr.  
Other

vehicle 1: Year:    Make:     Model:   

 Body Type:   Vehicle ID# (VIN):    Annual Mileage:

Business Use? Yes   No    Drive to school, work, station? Yes   No

If yes, number of miles one way:

Car Equipped With: Airbags? Yes   No   Anti-Theft Devices? Yes   No

4-Wheel Drive? Yes   No    Anti-Lock Brakes? Yes    No

vehicle 2:  Year:   Make:     Model:   

 Body Type:   Vehicle ID# (VIN):    Annual Mileage:

Business Use? Yes   No    Drive to school, work, station? Yes   No

If yes, number of miles one way:

Car Equipped With: Airbags? Yes   No   Anti-Theft Devices? Yes   No

4-Wheel Drive? Yes   No    Anti-Lock Brakes? Yes    No

If vehicle is kept at an address other than that listed above, please indicate:

Location City:    State:     Zip:

vehicle 3:  Year:   Make:     Model:   

 Body Type:   Vehicle ID# (VIN):    Annual Mileage:

Business Use? Yes   No    Drive to school, work, station? Yes   No

If yes, number of miles one way:

Car Equipped With: Airbags? Yes   No   Anti-Theft Devices? Yes   No

4-Wheel Drive? Yes   No    Anti-Lock Brakes? Yes    No

If vehicle is kept at an address other than that listed above, please indicate:

Location City:    State:     Zip:

Driver Information

Driver #1: first & last Name :    Occupation:

Relation to you:    Date of Birth (mm/dd/yy):    Gender: Male   Female

Marital Status: Married   Single   Completed: Driver's Education Course? Yes   No

Accident Prevention Course? Yes   No   Number of Years Licensed:

Distant student   Student GPA

Driver #2: first & last Name:    Occupation:

Relation to you:    Date of Birth (mm/dd/yy):    Gender: Male   Female

Marital Status: Married   Single   Completed: Driver's Education Course? Yes   No

Accident Prevention Course? Yes   No   Number of Years Licensed:

Distant student   Student GPA

Driver #3: first & last Name:    Occupation:

Relation to you:    Date of Birth (mm/dd/yy):    Gender: Male   Female

Marital Status: Married   Single   Completed: Driver's Education Course? Yes   No

Accident Prevention Course? Yes   No   Number of Years Licensed:

Distant student   Student GPA

Driver #4: first & last Name:    Occupation:

Relation to you:    Date of Birth (mm/dd/yy):    Gender: Male   Female

Marital Status: Married   Single   Completed:  Driver's Education Course? Yes   No

 Accident Prevention Course? Yes   No   Number of Years Licensed:

Distant student   Student GPA

Driver History

Has any driver listed:

1. Been convicted of any  traffic violations in the past 5 years? Yes    No

If yes, please answer the following:

Conviction #1   Driver:    Date:    Type:

Conviction #2   Driver:    Date:    Type:

Conviction #3   Driver:    Date:    Type:

Conviction #4   Driver:    Date:    Type:

2. Had his/her license suspended or revoked? Answer only if "Yes":

Driver #1:     Suspended? Yes   Revoked? Yes

Driver #2:     Suspended? Yes  Revoked? Yes

Driver #3:     Suspended? Yes  Revoked? Yes

Driver #4:     Suspended? Yes  Revoked? Yes

If yes to any suspended or revoked, which driver number   and how long were they suspended or revoked  Months:  Years:

3. Been convicted of driving under the influence of alcohol or drugs? Answer only if "Yes":

Driver #1:     Alcohol? Yes    Drugs? Yes

Driver #2:     Alcohol? Yes    Drugs? Yes

Driver #3:     Alcohol? Yes    Drugs? Yes

Driver #4:     Alcohol? Yes    Drugs? Yes

4. Have you had any claims and /or accidents, regardless of fault, over the past 5 years?

Yes    No

If yes, please answer the following:    amount paid

Claim/Accident #1   Driver:    Date:    Injuries? Yes    No

At Fault? Yes    No    Description:

Claim/Accident #2   Driver:    Date:    Injuries? Yes    No

At Fault? Yes    No    Description:

Claim/Accident #3   Driver:    Date:    Injuries? Yes    No

At Fault? Yes    No Description:

Claim/Accident #4   Driver:    Date:    Injuries? Yes    No

At Fault? Yes    No Description:

COVERAGE REQUESTED

1. Liability Limits for All Cars and pickup Trucks:

Choose either Bodily Injury:  and Property Damage:

Or choose Single Limit:

2. Uninsured Motorist Coverage for All Cars:

Choose either  single limits: or  split Limit:

3. Coverage for Medical Payments:

4. Deductibles and Additional Coverage:

vehicle 1:   Deductible - Comprehensive:    Deductible - Collision:

Towing: Yes    Loss of Use: Yes

vehicle 2:   Deductible - Comprehensive:    Deductible - Collision:

Towing: Yes    Loss of Use: Yes

vehicle 3:   Deductible - Comprehensive:    Deductible - Collision:

Towing: Yes    Loss of Use: Yes

 

Additional Comments

Please give any additional comments about the coverage you desire:

SUBMIT YOUR INFORMATION

Please review your entries for accuracy and click the "Submit" button below to send it to us. Use the "Reset" button to clear all your entries from the form.

note: Not a firm quote or binder. Final premium subject to verification of information.

Thanks for taking the time to fill out this form. One of our Auto Insurance representatives will contact you as soon as possible.

Auto Insurance ◊ Home Owners ◊ Life & Health ◊ General Liability ◊ Charter & Pleasure Boat Ins.
Commercial Auto ◊ Commercial / Business ◊ Surety Bonds ◊ Workers Comp ◊ Home

Questions? email us at Homer Insurance Center