255 West Uwchlan Avenue  
P.O. Box 1002
Downingtown, PA 19335
PHONE: (610) 269-4500
FAX 610-269-1922 or 610-269-0839

Monday thru Friday 8 am to 9 pm
Saturday 9 am to 5 pm

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Personal Information

Business Name :

Name :

Address :

Address :

City :

State :

Zip :

Please list names and ages of all drivers in household

Drivers :

Home Phone :

Work Phone :

Fax :

Email :

Vehicle Information

Vehicle 1

Year :

Make :

Model :

Annual Miles : 8500 or under over 8500

Usage : Business Pleasure Driven to Work

Miles to work (1 way) :

Vehicle has alarm? :

Alarm disables ignition? :

Antilock Breaks? :

Vehicle 2

Year :

Make :

Model :

Annual Miles : 8500 or under over 8500

Usage : Business Pleasure Driven to Work

Miles to work (1 way) :

Vehicle has alarm? :

Alarm disables ignition? :

Antilock Breaks? :

Vehicle 3

Year :

Make :

Model :

Annual Miles : 8500 or under over 8500

Usage : Business Pleasure Driven to Work

Miles to work (1 way) :

Vehicle has alarm? :

Alarm disables ignition? :

Antilock Breaks? :

Coverages Desired

Tort : Limited Full

Bodily Injury : 15/30 25/50 100/300 250/500

Property Damage : $50,000 $100,000

Medical Payments : $1,000 $3,000 $5,000

Un / Under Insured Motorists : 15/30 25/50 100/300 250/500

Road Service :

Rental Car Coverage : $20 per day $25 per day $30 per day

Deductible - Comprehensive : None $100 $250 $500 $1,000

Deductible - Collision : None $50 $100 $250 $500 $1,000

Accidents or Violations

Has any driver had any accidents or violations in the past three years?

Accidents / Violations :

Please Explain :