VERMONT Automobile Insurance Quotation Form
Please Note: WE CAN NOT QUOTE ON OUT OF STATE INSURANCE.

Mayo Associates, Inc.
49 Wall Street
Northfield, Vermont 05663
1-800-982-5849

To receive a quote, please fill out the form below

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Name:
Address:
City, St., Zip
Phone Number:
Email:

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Current Carrier Information and Expiration date of policy?

Company Name: Expiration date:

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Coverage Information..... LIABILITY LIMITS Split Limits Bodily Injury Limits: I have single limit (see below) 50,000 per person/ 100,000 per accident 100,000 per person/ 300,000 per accident 250,000 per person/ 500,000 per accident Property Damage Limit: n/a 25,000 per accident 50,000 per accident 100,000 per accident 250,000 per accident OR COMBINED SINGLE LIMIT Limit per Accident: n/a 100,000 per accident 300,000 per accident 500,000 per accident (Bodily Injury & Property Damage) Un and Underinsured Motorist Coverage Issued the same as liability limit for bodily injury. MEDICAL EXPENSE COVERAGE Medical Expenses............ 1,000 per person not included 5,000 per person 10,000 per person 50,000 per person 100,000 per person Vehicle Information YEAR MAKE MODEL VIN # USAGE COMP DED COLL DED 1 1 Pleasure Business Work > 3 miles Work < 3 miles n/a 100 250 500 1,000 n/a 100 250 500 1,000 Airbags #: 0 1 2 Automatic Seatbelts: Alarm System: ABS: NONE 2 wheel 4 wheel YEAR MAKE MODEL VIN # USAGE COMP DED COLL DED 2 2 Pleasure Business Work > 3 miles Work < 3 miles n/a 100 250 500 1,000 n/a 100 250 500 1,000 Airbags #: 0 1 2 Automatic Seatbelts: Alarm System: ABS: NONE 2 wheel 4 wheel YEAR MAKE MODEL VIN # USAGE COMP DED COLL DED 3 3 Pleasure Business Work > 3 miles Work < 3 miles n/a 100 250 500 1,000 n/a 100 250 500 1,000 Airbags #: 0 1 2 Automatic Seatbelts: Alarm System: ABS: NONE 2 wheel 4 wheel YEAR MAKE MODEL VIN # USAGE COMP DED COLL DED 4 4 Pleasure Business Work > 3 miles Work < 3 miles n/a 100 250 500 1,000 n/a 100 250 500 1,000 Airbags #: 0 1 2 Automatic Seatbelts: Alarm System: ABS: NONE 2 wheel 4 wheel Towing Conversion: Yes No Rental Reimbursement: Yes No

Driver Information

	Driver Name	BIRTH	LIC #	SEX	STATUS	OCCUPATION
1				Male Female	Married Single Divorced Widowed
2				Male Female	Married Single Divorced Widowed
3				Male Female	Married Single Divorced Widowed
4				Male Female	Married Single Divorced Widowed
5				Male Female	Married Single Divorced Widowed

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PERCENTAGE OF USE

V E H I C L E S	1	2	3	4	5
DRIVER # 1:
DRIVER # 2:
DRIVER # 3:
DRIVER # 4:
DRIVER # 5:

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Accidents and Violations

Does any driver have any accidents or violations? Yes No

If "YES", Please list ALL accidents and violations within last 3 years......

	DATE	DRIVER NAME	TYPE OF OCCURRENCE
1			NONE Speeding, minor Speeding, major Other minor violation Other major violation Suspended license At-fault accident < $1,000 At-fault accident > $1,000 Not-at-fault accident Comprehensive loss < $1,000 Comprehensive loss > $1,000
2			NONE Speeding, minor Speeding, major Other minor violation Other major violation Suspended license At-fault accident < $1,000 At-fault accident > $1,000 Not-at-fault accident Comprehensive loss < $1,000 Comprehensive loss > $1,000
3			NONE Speeding, minor Speeding, major Other minor violation Other major violation Suspended license At-fault accident < $1,000 At-fault accident > $1,000 Not-at-fault accident Comprehensive loss < $1,000 Comprehensive loss > $1,000
4			NONE Speeding, minor Speeding, major Other minor violation Other major violation Suspended license At-fault accident < $1,000 At-fault accident > $1,000 Not-at-fault accident Comprehensive loss < $1,000 Comprehensive loss > $1,000

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GENERAL INFORMATION

Where do you live? Own Home Own Condo Rent Home Rent Apartment Mobile Home Live with Parents

Any unrepaired damage to any vehicle of $ 200 or more? Yes No

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For additional information, please e-mail us at:

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MAYO@mayo-insurance.com

Call at 1-802-485-6061 or

1-800-982-5849

or fax us at 1-802-485-6065.

© 1996 Mayo Associates, Inc.
49 Wall Street
Northfield, Vermont 05663
MAYO@mayo-insurance.com