# Full Time:  # Part Time:

 Approx Annual Gross Receipts $:

Commercial Truckers Only                                                                                    Select Farthest Zone From Your Location - City 1st or Region 2nd

Select Zone Farthest From Location City Atlanta Baltimore-Washington Dc Boston Buffalo NY Charolotte Chicago Cincinnati Cleveland OH Dallas - Fort Worth Denver Detroit Hartford Houston Indianapolis Jacksonville FL Kansas City Little Rock Los Angeles Louisville Memphis Miami Milwaukee Minneapolis-St Pual Nashville New Orleans New York Oklahoma City Omaha Phoenix Philadelphia Pittsburgh Portland Richmond St Louis Salt Lake San Francisco Tulsa Regions Alaska Eastern - DE - ML - NJ - NY - PA Gulf - AL - LA - MS Mideast - KY - TN - WV Midwest - KA - MI - NE - ND - SD - WI Mountain - AZ - NM - UT - WY New England - CN - MA - Mass - NH - RI - VT North Central - IL - IN - OH - MI Pacific Coast - CA - OR - WA Southeast - FL - GA - NC - SC - VA - Southwest - AR - OK - Tx

Driver 1

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 2

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 3

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 4

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 5

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 6

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 7

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 8

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 9

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Driver 10

Full Name

Male Female

Marital Status Married Single Divorced Widow

At Fault Accidents/Major Violations  0 1 2 3 4 5

Not At Fault Accidents                    0 1 2 3 4 5

Minor Moving Violations/Tickets      0 1 2 3 4 5

Does Your Business Employ More Than 10 Drivers - Yes  No   

Vehicle Number

Year

Make / Type

Model /  Date Purchased / Cost

Vehicle ID Number

( This  is a 17 Digit Number)

Driver#

Weight / Usage / Miles / Trailer Hitch

Vehicle 1

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased  

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 2

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased    

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)  

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 3

Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 81+

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased    

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)  

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 4

Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 81+

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased   

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)  

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 5

Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 81+

Select Make Acura Advance Mixer Alfa Romeo Am General American Lafrance American Motors Aro Aston Martin Audi Autocar Avanti Bentley Bering Blubird Bmw Buick Cadillac Chance Chevrolet Chrysler Crane Carrier Daewoo Daihatsu Datsun Diamond Reo Dina Dodge Duplex Eagle Eagle Transit Eldorado Fahrzeugwerke Federal Motors Ferrari Fiat Flexible Ford Freightliner FWD Genesis Geo Gillig GM GMC Hendrickson Hino Honda Hyundai Infiniti International Isuzu Iveco Jaguar Jeep John Deere Kenworth Kia Kovatch Laforza Lamborghini Lancia Land Rover Lexus Lincoln Lodal Lotus Mack Marmon Maserati Mazda MCI (les Auto Bus) Mercedes Benz Mercury Merkur Mitsubishi Motor Coach Ind Inc Neoplan New Flyer Nissan Nissan Diesel North American Bus Nova Oldsmobile Ontario Orion Oshkosh Ottawa Peterbilt Peugeot Pierce Plymouth Pontiac Porsche Prevost Renault Roadmaster Rail Rolls Royce Saab Saturn Scania Seagraves Spartan Sterling Stewart & Stevenson Subaru Suzuki Thomas TMC Toyota Triumph TVR Utilimaster Van Hool Volkswagen Volvo Western Star White Whitegmc Winnebago Workhorse Yugo Other

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased   

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)  

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 6

Select Make Acura Advance Mixer Alfa Romeo Am General American Lafrance American Motors Aro Aston Martin Audi Autocar Avanti Bentley Bering Blubird Bmw Buick Cadillac Chance Chevrolet Chrysler Crane Carrier Daewoo Daihatsu Datsun Diamond Reo Dina Dodge Duplex Eagle Eagle Transit Eldorado Fahrzeugwerke Federal Motors Ferrari Fiat Flexible Ford Freightliner FWD Genesis Geo Gillig GM GMC Hendrickson Hino Honda Hyundai Infiniti International Isuzu Iveco Jaguar Jeep John Deere Kenworth Kia Kovatch Laforza Lamborghini Lancia Land Rover Lexus Lincoln Lodal Lotus Mack Marmon Maserati Mazda MCI (les Auto Bus) Mercedes Benz Mercury Merkur Mitsubishi Motor Coach Ind Inc Neoplan New Flyer Nissan Nissan Diesel North American Bus Nova Oldsmobile Ontario Orion Oshkosh Ottawa Peterbilt Peugeot Pierce Plymouth Pontiac Porsche Prevost Renault Roadmaster Rail Rolls Royce Saab Saturn Scania Seagraves Spartan Sterling Stewart & Stevenson Subaru Suzuki Thomas TMC Toyota Triumph TVR Utilimaster Van Hool Volkswagen Volvo Western Star White Whitegmc Winnebago Workhorse Yugo Other

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased   

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 7

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased   

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 8

Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 81+

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased  

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)  

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trialer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 9

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

Model    Date Purchased   

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)  

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Vehicle 10

Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 81+

Select Make Acura Advance Mixer Alfa Romeo Am General American Lafrance American Motors Aro Aston Martin Audi Autocar Avanti Bentley Bering Blubird Bmw Buick Cadillac Chance Chevrolet Chrysler Crane Carrier Daewoo Daihatsu Datsun Diamond Reo Dina Dodge Duplex Eagle Eagle Transit Eldorado Fahrzeugwerke Federal Motors Ferrari Fiat Flexible Ford Freightliner FWD Genesis Geo Gillig GM GMC Hendrickson Hino Honda Hyundai Infiniti International Isuzu Iveco Jaguar Jeep John Deere Kenworth Kia Kovatch Laforza Lamborghini Lancia Land Rover Lexus Lincoln Lodal Lotus Mack Marmon Maserati Mazda MCI (les Auto Bus) Mercedes Benz Mercury Merkur Mitsubishi Motor Coach Ind Inc Neoplan New Flyer Nissan Nissan Diesel North American Bus Nova Oldsmobile Ontario Orion Oshkosh Ottawa Peterbilt Peugeot Pierce Plymouth Pontiac Porsche Prevost Renault Roadmaster Rail Rolls Royce Saab Saturn Scania Seagraves Spartan Sterling Stewart & Stevenson Subaru Suzuki Thomas TMC Toyota Triumph TVR Utilimaster Van Hool Volkswagen Volvo Western Star White Whitegmc Winnebago Workhorse Yugo Other

Select Type Private Passenger Pickup Truck Dump Truck Tow Truck Courtsey Van Delivery Truck/Van Straight Truck Refrigerated Truck Flatbed Truck Stake Body Truck Tank Truck Miscellaneous Truck Van, Bus or Livery Tractor Garbage Truck

 Model    Date Purchased    

Cost New $ Current    $

1 2 3 4 5 6 7 8 9 10

Select Gross Vehicle Weight Private Passanger (0-5,000 lbs) Light Truck (0-10,000 lbs) Medium Truck (10,001-20,000 lbs) Heavy Truck (20,001-45,000 lbs) Heavy Truck-Tractor (0-45,000 lbs combined) Extra Heavy Truck (45,001 lbs or over)

Select Type Usage Executive - Private Passanger Outside Sales Service Retail Delivery Commercial Cagro - Freight

Radius Of Use - Regular Distance Traveled Local - up to 50 miles Intermediate - 51 to 200 miles Long Distance/Haul - over 200 miles

Select Annual Miles 0 to 10,000 10,000 to 25,000 25,000 to 50,000 50,000+

Select Type Trailer Hitch None Ball at bumper Ball in bed Gooseneck Tow Boom Fifth Wheel

Does Your Business Operate More Than 10 Vehicles?  No Yes   

 If "Yes"  please indicate total number of vehicles and we will email you a supplemental vehicle schedule )

Select Reject 40 50 75 80 120 Select Reject 50 100 200 250 500 1,000  Vehicle  Number

BI/PD

 UMBI/PD

  PIP/MED

COMP Ded

COLL Ded

Towing

                  Rental Car

Vehicle 1

Select Combined 1,000,000 Combined 500,000 Combined 300,000 BI250/500 PD100 BI100/300 PD100 BI50/100 PD50 BI25/50 PD25 BI20/40 PD15

Select Reject 20/40/15 25/50/25 50/100/50 100/300/100 250/500/100

Select Reject 1000 2500 5000 10000

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 2

 same as vehicle 1

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 3

 same as vehicle 1

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 4

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 5

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 6

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 7

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 8

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 9

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Vehicle 10

Select Reject 50 100 200 250 500 1,000

Select Reject 100 250 500 1000

Select Reject 40 50 75 80 120

Select Reject 30/900 35/1050 40/1350 45/1500 50/1500

Our Insurance Company Underwriters May Require Prior Carrier Generated Loss History Reports For Last 5 Years Prior To Binding Coverage.

 *Has your business had any losses or filed a commercial auto claim in the last five years? YesNo

If "Yes" Please Briefly Provide Details ( amount paid / carrier / policy # /  date of injury / nature of accident / injury sustained) or

Send Us Your Prior Insurers Valued Loss Runs For The Past 5 Years to:  edhemphill@hemphillinsuranceagency.com or fax (936) 448-1013.

1. 2. 3. 4. 5.

  General Underwriting Information: Please review each check box below to assure that each question is correctly answered; then change the checked box to the most appropriately response that applies to your request for a rate quote. Incorrect information may void the quick quote rate you receive.

 If you answered " Yes " to 1 through 18 above please indicate question # and briefly explain below: