Collectible Vehicle Insurance Quote Form
To receive a quote, please fill out the form below.....

 
 
 
Name:     Social Security #: 
Address:
City:   State:    Zipcode: 
Phone Number:
E-Mail Address:

Vehicle Useage
Are your collectible vehicle(s) used for any purpose other than car club, hobby activities or an occasional pleasure drive? Yes No
Are any collectible vehicles used for racing?
Yes
No
Are any collectible vehicles used for commercial purposes? Yes No
Are any collecible vehicles used for backup or substitute transporation? Yes No
What purpose are the collectible vehicles driven for? 

Current Carrier Information and Expiration date of policy?
Company Name:     Expiration date: 

Limits
Single Limit per Accident (Bodily Injury/Property Damage)
Un & Underinsured Motorist Coverage per Accident     Stacking? Yes / No
$  Spare Parts Coverage
TORT OPTION:  "Limited" Tort limits your ability to sue, "Full" Tort does not.
Pennsylvania First Party Benefits
Please select plan....
$ 5,000 Medical Expenses
$ 1,000 Monthly Work Loss Benefit ($ 5,000 Maximum)
$ 1,500 Funeral Expenses
none Accidental Death Benefit
$ 10,000 Medical Expenses
$ 1,000 Monthly Work Loss Benefit ($ 5,000 Maximum)
$ 1,500 Funeral Expenses
none Accidental Death Benefit
$ 50,000 Medical Expenses
$ 1,500 Monthly Work Loss Benefit ($ 25,000 Maximum)
$ 1,500 Funeral Expenses
$ 10,000 Accidental Death Benefit
$ 100,000 Medical Expenses
$ 2,500 Monthly Work Loss Benefit ($ 50,000 Maximum)
$ 2,500 Funeral Expenses
$ 25,000 Accidental Death Benefit

Vehicle Information
Vehicle 1----->
Year Make Model Vehicle Identification # Current
Value		 Custom Paint Comp
Ded		 Coll
Ded
Annual Mileage:  Alarm System: 

Vehicle 2----->
Year Make Model Vehicle Identification # Current
Value		 Custom Paint Comp
Ded		 Coll
Ded
Annual Mileage:  Alarm System: 

Vehicle 3----->
Year Make Model Vehicle Identification # Current
Value		 Custom Paint Comp
Ded		 Coll
Ded
Annual Mileage:  Alarm System: 

Vehicle 4----->
Year Make Model Vehicle Identification # Current
Value		 Custom Paint Comp
Ded		 Coll
Ded
Annual Mileage:  Alarm System: 

Driver Information
Driver Name Birth Years Licensed Sex Marital Status License # 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


Accidents and/or 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

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) 327-7911
Toll Free: 1-800-977-2999    (Fax) 1-888-800-0034
www.McGrathInsuranceGroup.com                McGrathInsurance@aol.com