Name Date of Birth S.S.# Current Date

                      Married          Single         Divorced         Separated

             Spouse Name  Date of Birth S.S.#

                        Address   Own/Rent

                 Home Phone Work Cell Fax

                Email Address

                   List below all people who currently reside in the household including family members, persons under 21 in the care of the insured (including foster children), and other

            Name                   DOB        Relationship         S.S.#                    Rated/Excluded

5 year loss/violation history

    Date of loss         Open/Closed        PD Amount               Description                    Driver

     Year        Make/Model         Use                VIN#                 Operator              Coverage's        

Vehicle(s) titled in your name    yes  no   If no - who is the titleholder

                 Are any vehicles used in connection with a business?   yes no                            If so please describe

                      Do any of the vehicles have existing damage?   yes no                                  If so please describe

                             Any vehicle loaned regularly to others   yes no                                      If so please describe

        Are any VEH kept at boarding school/college during the school year   yes no

                                     Distance of school or college     miles

     If pickup or SUV, does the insured use the VEH for snowplowing or towing  yes no

         Current insurance  yes no       If yes then what company

       EXP. Date    Six months prior   yesno    Prior liabilities

       Do you have health insurance   yesno     If yes then what company

                Are you a member of Consumers Credit Union, Sam's Club, AARP or any other            association or group    yesno Which one(s)

              Pay monthly or in full

          ***IN CONNECTION WITH THIS QUOTE FOR INSURANCE, WE MAY OBTAIN YOUR INSURANCE SCORE WHICH IS CREDIT BASED.