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Name* Address* City* State* Select Pennsylvania Zip:* Please supply either a Daytime or Evening Phone Number and the best time to call. Day Time Number: Evening Number: (570) Best Time To Call* Select Morning Afternoon Evening E-mail:* Request Auto Insurance Do you currently own your own home* Select Yes No Current insurance carrier* (If you do not have a current insurance carrier type in NONE) How Long*   years Policy Expiration Date Driver Information Driver1* Driver2 Driver3 Name* License #* Soc. Sec #* Sex* Select Male Female Select Male Female Select Male Female Date of Birth* Tickets in last 3 years* Accidents in last 3 years* Years Licensed* Daily Commute  miles  miles  miles Vehicle Information Vehicle1* Vehicle2 Vehicle3 Year* Make* (i.e. Pontiac) Model/Trim (i.e. Bonneville) Body Style (i.e. 2-door) Cylinders Select 4 6 8 10 12 Select 4 6 8 10 12 Select 4 6 8 10 12 Passive Restraints* Select NONE 1airbag 2 airbags Auto Seatbelts Select NONE 1airbag 2 airbags Auto Seatbelts Select NONE 1airbag 2 airbags Auto Seatbelts Anti-Theft Device* Select None active (i.e. Lo-jack) passive (i.e. Car alarm) Select None active (i.e. Lo-jack) passive (i.e. Car alarm) Select None active (i.e. Lo-jack) passive (i.e. Car alarm) Used for Business Select Yes No Select Yes No Select Yes No Total Annual Miles VIN# Limit of Liability $ Select State Minimum 20/40K 50/100K 100/300K 250/500K $ Select State Minimum 20/40K 50/100K 100/300K 250/500K $ Select State Minimum 20/40K 50/100K 100/300K 250/500K Limit of Property Damage $ Select State Minimum 15K 25K 50K 100K $ Select State Minimum 15K 25K 50K 100K $ Select State Minimum 15K 25K 50K 100K Comprehensive Deductible $ Select NONE 0 100 200 250 500 1000 $ Select NONE 0 100 200 250 500 1000 $ Select NONE 0 100 200 250 500 1000 Collision Deductible $ Select NONE 0 100 200 250 500 1000 $ Select NONE 0 100 200 250 500 1000 $ Select NONE 0 100 200 250 500 1000 1st Party Medical Expenses (If other, please specify $ Select 5000 10000 25000 50000 100000 other $ Select 5000 10000 25000 50000 100000 other $ Select 5000 10000 25000 50000 100000 other 1st Party Income Loss (If other, please specify $ Select NONE 1000/5000 1000/15000 1000/25000 2500/50000 5000/100000 other $ Select NONE 1000/5000 1000/15000 1000/25000 2500/50000 5000/100000 other $ Select NONE 1000/5000 1000/15000 1000/25000 2500/50000 5000/100000 other Accidental Death (If other, please specify $ Select NONE 5000 10000 25000 1000 $ Select NONE 5000 10000 25000 1000 $ Select NONE 5000 10000 25000 1000 Funeral Expenses (If other, please specify $ Select NONE 1500 2500 other $ Select NONE 1500 2500 other $ Select NONE 1500 2500 other Transportation Expenses (If other, please specify $ Select NONE 20/day 30/day 35/day other $ Select NONE 20/day 30/day 35/day other $ Select NONE 20/day 30/day 35/day other Uninsured Motorist $ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000 $ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000 $ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000 Underinsured Motorist $ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000 $ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000 $ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000 Underinsured/Uninsured Stacking Applies $ Select stacked unstacked $ Select stacked unstacked $ Select stacked unstacked Tort Option $ Select limited full $ Select limited full $ Select limited full Road Service $ Select yes no $ Select yes no $ Select yes no Additional Information: (If you have any ticket or accidents please explain here Also provide information about fourth driver and/or vehicle here) NOTE: All asterisked* fields must be completed for a successful submission. Thanks! One of our agents will contact you shortly with your proposed coverage

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790 Northern Boulevard
Clarks Summit, PA 18411