Bill Higley Insurance - Skip Molen, Agent
Insurance - Auto, Home, Commercial, Life, Bonds, Medical
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First Name:
Initial:
Last Name:
Email:
Address Line 1:
Address Line 2:
City:
County:
State:
Zip:
Date Moved to Current Address:
Work Phone:
Home Phone:
If you are married, who has better credit rating:
Myself
Spouse
Not Married
List All Drivers to be Insured
Name:
Relation:
DOB:
DL#:
Tickets/Accidents in last 3 years - Describe in detail including type of ticket/accident, fault, etc
Name:
Relation:
DOB:
DL#:
Tickets/Accidents in last 3 years - Describe in detail including type of ticket/accident, fault, etc
Name:
Relation:
DOB:
DL#:
Tickets/Accidents in last 3 years - Describe in detail including type of ticket/accident, fault, etc
Name:
Relation:
DOB:
DL#:
Tickets/Accidents in last 3 years - Describe in detail including type of ticket/accident, fault, etc
Insurance Limits
Bodily Injury:
25/50
50/100
100/300
250/500
Property Damage:
25
50
100
250
UM Bodily Injury
25/50
50/100
100/300
250/500
UM Property Damage:
10,000
15,000
20,000
25,000
Pip:
15,000
20,000
25,000
250
*UM = Uninsured Motorist
Transfer/Renewal
Current Insurer:
Months Insured:
Days Lapsed:
Current Auto Liability:
25/50
50/100
100/300
250/500
Residence/Work
Residence:
Own Home
Own Condominium
Own Mobile Home
Rent Apt.
Rent House
Lives With Parents
Months in Home:
Months in Present Job:
HO/Renters Insurance:
Months in State:
Months Working in State:
Vehicles to Insure - Vehicle 1
Year:
Make:
Model:
VIN:
Usage:
Pleasure
Commute to Work or School
Commute Mileage:
Mileage/Year:
Ownership:
Owned by Insured
Owned by Other
Garaging Zip Code:
Coverages:
Comprehensive Deductable:
100
250
500
Collision Deductable:
100
250
500
Towing:
Rental:
Add On Equipment:
Physical Damage Only:
Uninsured Mortorist Paid:
Car Loan Protection:
Lienholder Deductable:
Vehicles to Insure - Vehicle 2
Year:
Make:
Model:
VIN:
Usage:
Pleasure
Commute to Work or School
Commute Mileage:
Mileage/Year:
Ownership:
Owned by Insured
Owned by Other
Garaging Zip Code:
Coverages:
Comprehensive Deductable:
100
250
500
Collision Deductable:
100
250
500
Towing:
Rental:
Add On Equipment:
Physical Damage Only:
Uninsured Mortorist Paid:
Car Loan Protection:
Lienholder Deductable:
Vehicles to Insure - Vehicle 3
Year:
Make:
Model:
VIN:
Usage:
Pleasure
Commute to Work or School
Commute Mileage:
Mileage/Year:
Ownership:
Owned by Insured
Owned by Other
Garaging Zip Code:
Coverages:
Comprehensive Deductable:
100
250
500
Collision Deductable:
100
250
500
Towing:
Rental:
Add On Equipment:
Physical Damage Only:
Uninsured Mortorist Paid:
Car Loan Protection:
Lienholder Deductable:
Vehicles to Insure - Vehicle 4
Year:
Make:
Model:
VIN:
Usage:
Pleasure
Commute to Work or School
Commute Mileage:
Mileage/Year:
Ownership:
Owned by Insured
Owned by Other
Garaging Zip Code:
Coverages:
Comprehensive Deductable:
100
250
500
Collision Deductable:
100
250
500
Towing:
Rental:
Add On Equipment:
Physical Damage Only:
Uninsured Mortorist Paid:
Car Loan Protection:
Lienholder Deductable:
Note: For a copy, print this form.
