Please fill out this form completely to receive your quote:
Your Personal Data
Name (required):
Street Address:
City
State:
Zip Code:
E-mail Address (required):
Phone Number:
Fax Number:
Marital Status
Single    Married 		Homeowner
Yes    No
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
a DL123 FILING?		 Yes No If YES to DL123 filing, why needed?
(list accident/cite)
DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an DL123 FILING?		 Yes No Comments or
Remarks?
VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of
Liability:		 $30/60 BI / 25 PD $50/100 BI / 50 PD
$100/300 BI / 50 PD $250/500 BI / 100 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of
Liability:		 $30/60 BI / 25 PD $50/100 BI / 50 PD
$100/300 BI / 50 PD $250/500 BI / 100 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?		 Yes No   Uninsured
  Motorists Cov.?		 Yes No
Comments or Remarks:
(List additional drivers, autos, etc. here)
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The Reinard Insurance Agency, Inc.
349 Bustleton Pike
Feasterville, PA 19053 (Directions)
Ph: 215-357-8600
Fx: 215-357-8061