Pennsylvania Auto Insurance Quote Request Form

Auto Insurance Quote Form Pennsylvania Only

To receive a quote, please fill out the form below.....

Name:	Social Security #:
Address:
City:	State: Zipcode:
Phone Numbers:
E-Mail Address:
Do you belong to any of these groups?

Current Carrier Information and Expiration date of policy?

Your Current Insurance Company Name:

Policy Expiration date:

Tort Option: "Limited" Tort limits your ability to sue, "Full" Tort does not.

Liability Limits

Bodily Injury Limit / or Single Limit per Accident	Property Damage Limit

Un and Underinsured Motorist Coverage

Limit Option:

Stacked / Non-Stacked

Pennsylvania First Party Benefits
Please select either Selected First Party Benefits or Combined Benefits

S E L E C T E D F I R S T P A R T Y B E N E F I T S

Medical Expenses	Work Loss Benefits	Funeral Expenses	Accidental Death Benefits

C O M B I N E D F I R S T P A R T Y B E N E F I T S

Per Person Limit: (Medical Expenses & Work Loss Benefits/Funeral Expenses/Accident Death Benefit)

Do you need Work Loss Benefits?

Extraordinary Medical Benefits (Medical Expenses from $100,001 to....)
Benefit Limit:

VEHICLE INFORMATION
Vehicle 1

Year	Make	Model	Vehicle Identification #	On Star User	Usage	Comprehensive Ded	Collision Ded
				Yes / No

RESTRAINTS

ANNUAL MILEAGE

ALARM SYSTEM

ABS BRAKES

Vehicle 2

Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded Collision
Ded

Yes / No

RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES

Vehicle 3

Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded Collision
Ded

Yes / No

RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES

Vehicle 4

Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded Collision
Ded

Yes / No

RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES

Vehicle 5

Year Make Model Vehicle Identification # On Star User Usage Comprehensive
Ded Collision
Ded

Yes / No

RESTRAINTS
ANNUAL MILEAGE
ALARM SYSTEM
ABS BRAKES

DRIVER INFORMATION

Driver Name	Birth	Years Licensed	Sex	Marital Status	License #	Occupation *	Defensive Driving Course or Driver Training Course In the last 3 years	If student, QPA
							Yes / No
							Yes / No
							Yes / No
							Yes / No
							Yes / No

* Occupation is now needed: Insurance companies are now asking for the driver's occupation because they are now using it in the rating structure

PERCENTAGE OF USE

	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4	Vehicle 5
Driver # 1:	%	%	%	%	%
Driver # 2:	%	%	%	%	%
Driver # 3:	%	%	%	%	%
Driver # 4:	%	%	%	%	%
Driver # 5:	%	%	%	%	%

ACCIDENTS & 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

GENERAL INFORMATION

Where do you live?

Any unrepaired damage to any vehicle of 200 or more?

How many years have you been with your existing insurance company?

Are you a member of AAA? Yes No

		(After you Submit) For better auto rates, please quote my HOMEOWNERS/RENTERS INSURANCE
Home Page	E-Mail

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474           Fax: (724) 327-7911
Toll Free: 1-800-977-2999      Fax: 1-888-800-0034