Auto Quote Sheet Agent: Quote Date:Quote Time

Auto Quote SheetAgent: Quote Date:Quote Time:

Reason for Policy:Effective Date: Term Length: 6 mo. 12 mo.

Other Polices:Payment Method: EFT or Mail/Cash Payments: 1 2 5 6 10 12

First Named Insured:Email:

Home Phone:Cell Phone:Work Phone:Preferred Contact:

Total Number in Home:Address:

How Long in Home:Mail:

Rent OwnOtherWith Parents Mobile HomeHow did you hear about us:

Prior Carrier:Current: Y NIssue Date:Expiration Date:

Liability Limits:Comp. Deduct:Length of Continuous Coverage:

PIP Limits:Collis. Deduct:Any Cancels/ Lapses: Y N Days Lapsed:

UM/UIM Liability Limits:Reason For Lapse:

Misc. Coverages & Limits:

Driver Information For All Drivers In House or At College

# / Name / Relation / M/F / Marital Status / Education / Occupation / Driver Status / Military
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2
3
4
5
6
# / License # / DOB / SSN / State / Issued / Expires / Status / SR-22 / International
1
2
3
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5
6

Please fill this form out accurately and completely to ensure accurate quotes. See reverse side for answer options.

Incomplete forms may possibly still be quoted, but quoted rates are subject to change as information is collected.

Vehicle Information

# / YR / Make / Model / VIN Number / Style / Type / Principle Driver / Zip of Alt. Garage
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# / Usage / 1 Way Miles / Days Driven Per Week / Annual Miles / Non-Owned / Delivery / ABS / 4x4 / Air Bags
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6

Recreational Vehicle Information

# / YR / Make / Model / Value / VIN / Length / Vehicle Usage / Type
1
2

Lien Information

# / Name / Address / Loan #/ VIN / Comments
1
2
3
4

Comprehensive, At-Fault, No-Fault Accidents or Violations/Tickets

DATE / TYPE / DESCRIPTION / DRIVER / AMOUNT

Discount Questions (List Driver # and Vehicle #)

Good Student:Anti-Theft Alarm:

Distant Student:Active Anti-Theft:

Driver’s Ed:Passive Anti-Theft:

Accident Prevention:Auto Seat Belts:

Mass Transit Pass:Electronic Stability Control:

Car Pool:Enroll in Snapshot: Y NPaperless Policy: Y N

Answer Options

Marital Status: Single; Married; Separated; Divorced; Widowed

License Status: Valid; Permit; Suspended; Expired; Commercial

Driver Status: Rated; Non-Rated; Other Insurance; Never Licensed; Revoked; Out of Country; Incarcerated; Disabled

Usage: Pleasure; Commute; Business Use; Service Use; Farming

Vehicle Type: Stated Amount; Van/Pickup/Utility; Unlisted; Custom; Named Operator

RV Vehicle Type: Motor Home: Class A, Class B, Class C, Bus Conversion; Toter Home; Pop-Up; Camper; 5th Wheel; Conventional

RV Usage: < 30 Days; 30-150 Days; >150 Days; Primary Residence

Body Style: Hard Top; Sedan; Station Wagon; Convertible; SUV; Minivan; Pickup Cost New; Pickup Symbol

Notes/Comments/Additional Information:

Coverages & Limits ( in thousands) Please Circle

BI
Person / Occurrence
$25* / $50*
$50 / $100
$100 / $300
$250 / $500
$500 / $500
UM/UIM BI
Person / Occurrence
$25* / $50*
$50 / $100
$100 / $300
$250 / $500
$500 / $500
CSL
$60
$100
$300
$500

Comp Deduct / $100.00 / $200.00 / $250.00 / $500.00 / $750.00 / $1000.00
Coll Deduct / $100.00 / $200.00 / $250.00 / $500.00 / $750.00 / $1000.00
Rental (per day) / $20.00 / $25.00 / $30.00 / $35.00 / $40.00 / $50.00 / $75.00
Tow (per occurrence) / $50.00 / $100.00 / $200.00 / $250.00

These Coverages, Limits, and Deductibles represent every option from our various carriers. Most carriers share options but to ensure accurate quotes from all of our carriers, please indicate whether you would like to be quoted with the higher or lower option. Higher limits offer greater protection but have increased premiums. Having higher deductibles will lower your premium costs but you will have to pay that amount before your limits will begin to cover your loss.

Limits: Higher LowerDeductible: Higher Lower

*Denotes State Minimum Limits. 25/50 Liability Limits Available for Named Operators Only. RKI requires 50/100 for liability limits in most circumstances to ensure client is covered in case of loss.