L&K Insurance

Automobile Insurance Quotation f o r m

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION
Your name:	First: Last:
E-Mail address:
Phone numbers:	Daytime:
	Evening:
	Fax:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
If you would prefer to be contacted by phone, please let us know the best time to call.
Address:
City:
State:
Zip code:
If you are a Hy-Vee Employee- Store Location
# of Years Employed at Hy-Vee
Department
Do you currently own your home, or rent?	Own Rent
Driver's license number:
Social security number:

DRIVER INFORMATION
	Name:	Relationship to applicant:	Sex:	Marital status:	Social Security number:	Driver's License number:	Date of birth:	Which vehicle does he/she drive?	Percent use:
Driver #1			M F	M S
Driver #2			M F	M S
Driver #3			M F	M S
Driver #4			M F	M S

DRIVER HISTORY
Do you currently have insurance?		Yes No
If yes- Currently insured with (company name not agency):
Policy Number
Have you or any other driver in your household:
Had a ticket in the last 3 years?	Had a license suspended or revoked in the last 6 years?	Had a financial responsibility filing in the last 6 years?	Made any claims in the last 5 years?
Yes No	Yes No	Yes No	Yes No
If you answered yes to any of the above questions, please explain:

VEHICLE #1 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #2 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #3 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

VEHICLE #4 INFORMATION
Year:	Make:	Model:	Vehicle ID# (VIN):

Primary driver:	Annual mileage:	Is the vehicle driven to school or work?	If driven to school or work, how many weeks per month?	If driven to school or work, how many miles one way?
		Yes No	Days Weeks	Miles
Is the vehicle in any way modified or customized?			Is there any existing damage to the vehicle?
Yes No			Yes No
If vehicle is kept at an address other than that listed above, please indicate below:
Address: City: State: Zip:

COVERAGE OPTIONS
Bodily injury liability:
Property damage liability:
Underinsured motorist-bodily injury:
Underinsured motorist-property damage:
Uninsured motorist:
Medical-personal injury protection:
Accidental death:

COVERAGE DEDUCTIBLES
	Comprehensive deductible:	Collision deductible:	Towing coverage:
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4

QUESTIONS, COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?