•
GENERAL INFORMATION
TERM:
6 Months
Date Submitted:
Effective Date:
Name of Insured:
Home Phone #:
(
) -
Benefits Plus Client?
Yes
No
Benefits Plus Number
Alternate Garaging:
•
AUTO 1 INFORMATION
Year:
Make/Model:
I.D. Number:
Use:
Comp:
None
250
500
Coll:
None
250
500
Tow:
None
50
75
(RR)-Rental:
None
20/600
Airbag:
ABS:
Anti-Theft:
Oper # % of Use:
•
AUTO 2 INFORMATION
Year:
Make/Model:
I.D. Number:
Use:
Comp:
None
250
500
Coll:
None
250
500
Tow:
None
50
75
(RR)-Rental:
None
20/600
Airbag:
ABS:
Anti-Theft:
Oper # % of Use:
•
COVERAGE LIMIT/DEDUCTIBLE
BI/PD:
10/20/10
25/50/25
50/100/50
100/300/50
100/300/100
MED Pay:
None
500
1000
2000
UM:
None
10/20
25/50
50/100
Limits:
STKD:
Non-STKD:
PIP:
Basic:
Extend:
DED Applies to:
NI
NI/REL
Military Benefits Coordinate:
Work Less EXCL:
Work Less INCL:
List Violations, Accidents, Operator#:
SR22 Required/Operator Number :
Total Premium/Tier:
Has the Insured been Notified that Travelers will be Running Reports on Them?:
Yes
No
•
OPERATOR 1 INFORMATION
Name:
Sex:
Male
Female
Marital Status:
Date of Birth:
Date of License:
Good Student:
Def Drvr:
Excld Drvr:
Driver's License #:
Social Security #:
•
OPERATOR 2 INFORMATION
Name:
Sex:
Male
Female
Marital Status:
Date of Birth:
Date of License:
Good Student:
Def Drvr:
Excld Drvr:
Driver's License #:
Social Security #:
Does Insured Owned Home/Mobile Home?
Yes
No
Prior Insurance?
Yes
No
# of Months with Prior Insurance:
Days Lapse:
Did Prior Insurance Include BI?:
Yes
No
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For more Information, please call:
R.V. Howard & Associates, Inc.
8487 S. US 1 Port St. Lucie, FL 34952
Tel.: (772) 343-9878
Fax: (772) 343-9884
Email:
PersonalLines@rvhoward.com
