Huntress Insurance - Auto Quote Form

ONLINE AUTO QUOTE FORM

COVERAGES PART 1-12

AUTO 1

AUTO 2

Compulsory Insurance

Limits/Deductible

1. Bodily Injury To Others

$20,000 per person/$40,000 Accident

2. Personal Injury Protection

$8,000 per person

3. Bodily Injury Caused By An Uninsured Auto (Compulsory) Limits $20,000/$40,000

4. Damage To Someone Else's Property (Compulsory) Limits ($5,000)

OPTIONAL INSURANCE

5. Optional Bodily Injury To Others: Guest Occupant Exclusion For Motorcycle

THIS PROTECTS YOU IF
YOU ARE SUED!!!!!

6. Medical Payments

7. Collision

Yes No

If YES deductible

Yes No

If YES deductible

8. Limited Collision

Yes No

9. Comprehensive

Yes No

If YES deductible

Yes No

If YES deductible

10. Substitute Transportation

Yes No

If YES per day

Yes No

If YES per day

11. Towing & Labor

Yes No

If YES

Based on underwriting requirements

Yes No

If YES

Based on underwriting requirements

12. Bodily Injury Caused By An Underinsured Auto

VEHICLE INFORMATION

Principal Garaging City or Town- Auto 1

Principal Garaging City or Town - Auto 2

Year

Make, Model

Est. Annual Mileage

Air Bag/Passive Seat Belt

Yes No

Air Bag/Passive Seat Belt

Yes No

Anti-Theft

Yes No

Anti-Theft

Yes No

Recovery System

Yes No

Recovery System

Yes No

DRIVER INFORMATION Furnish Information for the applicant & each individual who operates the auto (s)

#
Name
Date of

Birth
Driver's License #/ State
Date First License

Driver Training
% of Use*

1
First

Last

Mass
Other Yes No
Auto 1

Auto 2

2
First

Last

Mass

Other

YesNo
Auto 1

Auto 2

3
First

Last

Mass
Other
YesNo
Auto 1

Auto 2

4
First

Last

Mass

Other

YesNo
Auto 1

Auto 2

5
First

Last

Mass

Other

YesNo
Auto 1

Auto 2

6
First

Last

Mass

Other

YesNo
Auto 1

Auto 2

How do you prefer to be notified?

Name

Phone#or

Email Address

Honor Roll Student

School Greater than 100 miles away?

Loss Free for 6 years?

In Control Advanced Driver Training?

Years lived at current location

Roadside Assistance Member (AAA or Autoclub)?

Would you consider paying in full to save 3%?

* required field

THANK YOU