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General Information: First Name: Middle Initial: Last Name: Address: Address: City: State:    Zip:    Phone:   Fax:    E-mail Auto Information - Car 1: Vehicle Year:    Vehicle Make:    Vehicle Model: VIN: (Optional) Type: 2 Door 4 Door Station Wagon Van Pickup4x2 Pickup4x4 HCHBK Primary Use: Work/SchoolPleasureBusiness Use Cost New (Optional): Comprehensive Deductible: $50 $100 $200 $500 $1000 $50Full Glass $100Full Glass $200Full Glass $500Full Glass $1000Full Glass Collision Deductible: $100 $200 $250 $500 $1000 Options: Driver Airbag Audible Alarm Homing Device   Passenger Airbag Automatic Seatbelts Anti-lock brakes   VIN Etching Passive Alarm   Car 2: Vehicle Year:    Vehicle Make:    Vehicle Model: VIN: (Optional) Type: 2 Door 4 Door Station Wagon Van Pickup4x2 Pickup4x4 HCHBK Primary Use: Work/SchoolPleasureBusiness Use Cost New (Optional): Comprehensive Deductible: $50 $100 $200 $500 $1000 $50Full Glass $100Full Glass $200Full Glass $500Full Glass $1000Full Glass Collision Deductible: $100 $200 $250 $500 $1000 Options: Driver Airbag Audible Alarm Homing Device   Passenger Airbag Automatic Seatbelts Anti-lock brakes   VIN Etching Passive Alarm   Car 3: Vehicle Year:    Vehicle Make:    Vehicle Model: VIN: (Optional) Type: 2 Door 4 Door Station Wagon Van Pickup4x2 Pickup4x4 HCHBK Primary Use: Work/SchoolPleasureBusiness Use Cost New (Optional): Comprehensive Deductible: $50 $100 $200 $500 $1000 $50Full Glass $100Full Glass $200Full Glass $500Full Glass $1000Full Glass Collision Deductible: $100 $200 $250 $500 $1000 Options: Driver Airbag Audible Alarm Homing Device   Passenger Airbag Automatic Seatbelts Anti-lock brakes   VIN Etching Passive Alarm   Liability Limits: Liability Coverage Limits:                     $50K/Combined Single Limit $100K/Combined Single Limit $300K/Combined Single Limit $500K/Combined Single Limit $1Mill./Combined Single Limit $50K/Pers.,$100K/Acc.,$50K/Prop. $100K/Pers.,$300K/Acc.,$100K/Prop. $250K/Pers.,$500K/Acc.,$100K/Prop. $500K/Pers.,$1Mill./Acc.,$200K/Prop. Uninsured/ Supplementary Underinsured Motorist Coverage: $25K/Combined Single Limit,$50K/Acc. $50K/Combined Single Limit          $100K/Combined Single Limit $300K/Combined Single Unit $500K/Combined Single Unit $1Mill./Combined Single Unit $50K/Person,$100K/Acc. $100K/Person,$300K/Acc. $250K/Person,$500K/Acc. $500K/Person,$1Mill./Acc. Property Damage: $25K $50K                          $100K $200K $300K $500K Medical Payments: $1K                            $2K $3K $5K $10K $25K $50K $75K $100K Personal Injury Protection: $50,000 $75K                          $100K $150K OBEL: Yes Driver Information:   Driver 1 Driver 2 Driver 3 First Name: Middle Name: Last Name: NY Drivers License #: Date of Birth: (00/00/00) Gender: Male         Female Male         Female Male         Female Marital Status: Single Married        Divorced Widowed Single Married        Divorced Widowed Single Married        Divorced Widowed Credits: None Driver's Education Defensive Driving Course Other None Driver's Education Defensive Driving Course Other None Driver's Education Defensive Driving Course Other Please check any Violations for each driver in the last three years: None Speeding(less than 15 mph over limit) Speeding(more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other None Speeding (less than 15 mph over limit) Speeding (more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other None Speeding (less than 15 mph over limit) Speeding (more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other Please check any Accidents for each driver in the last three years: None At fault accident Not at fault accident Hit and Run Other None At fault accident Not at fault accident Hit and Run Other None At fault accident Not at fault accident Hit and Run Other Current Auto Insurance Company (Optional): Current Home Insurance Company (Optional): For more information on our personal auto products and companies, please contact: Karen Annechino or       E-mail: kannechino@dgmagency.com Tessa Hewitt       E-mail: thewitt@dgmagency.com