Transcription of Auto - Cottonwood Insurance
1 auto Insurance Questionnaire Name Phone Number Email Address Cell phone Address (including ZIP). auto Information Year Make Model VIN Liability only 1 Y/N. 2 Y/N. 3 Y/N. 4 Y/N. Driver Information Name Sex DOB Social Security # Drivers license #. 1. 2. 3. 4. Violations and Accidents List all accidents and violations that have occurred in the last 3 years. Driver Date Type Current or desired Insurance Coverage Please circle desired coverages Coverage Limit Vehicle #. Bodily Injury Liability 25/50 50/100 100/300 250/500. Property Damage 25 50 100 250. Personal Injury 3000 5000 10000. Comp Deductible 100 200 500 750 1000. Coll Deductible 100 200 500 750 1000.
2 Uninsured Motorist B. I. 25/50 50/100 100/300 250/500. Uninsured Motorist P. D. 25/50 50/100 100/300 250/500. Underinsured Motorist 25/50 50/100 100/300 250/500. Towing Coverage 0 25 50 75 100. Rental Car Coverage 20/day 25/day 30/day 40/day 50/day Additional needs or concerns with policy
