MID-ALLIANCE INSURANCE

Auto Insurance

Name :

Address :

City :

State :

Nebraska

Zip code :

County :

Telephone :

Fax :

Email :

Current Insurance Company :

Present Policy Expires :

Current Premium :

Driver Information

Driver 1

Driver 2

Driver 3

Driver 1 Name :

Birth date :

Driver's License Number:

Social Security Number:

Years you have been licensed :

Gender :

Marital Status:

Do you qualify for a good student discount? :

Yes No

Percent time driving :

Car 1 :

Car 2 :

Car 3 :

Automobile Information

Vehicle 1

Vehicle 2

Vehicle 3

Year :

Make (i.e. Ford) :

Model (i.e. Taurus) :

VIN Number:

Body Type (2 or 4 door Wagon) :

What do you use your vehicle for?

Do you drive to work or school?

Yes No

How many miles do you drive? (one-way)

How many days do you drive to work/school per week?

How many miles do you drive total, per year?

Coverage Requested

Liability
Bodily Injury/Property Damage $50,000/100,000/25,000 $100,000/300,000/50,000 $250,000/500,000/100,000 Do you have another amount you would prefer?	OR	Combined Single Limit $100,000 $300,000 $500,000

Medical Payments $1,000 $2,000 $5,000 Do you have another amount you would prefer?	Uninsured Motorists Limit Equal to Liability Limit
Comprehensive Vehicle 1: Vehicle 2: Vehicle 3:	Collision Vehicle 1: Vehicle 2: Vehicle 3:
Rental Reimbursement Vehicle 1 Vehicle 2 Vehicle 3	Towing and Labor Vehicle 1 Vehicle 2 Vehicle 3

Within the last five years, has any driver had any accidents (regardless of fault), traffic violations, or other vehicle losses (for example, vandalism or towing)?
Yes No

Please describe accidents and violations in the past 5 years

#	Accidents-Given Description	At Fault (Yes/No)	Date
1
2
3

#	Traffic Violation Incl. MPH Over Speed Limit	Date
1
2
3

Any additional quotes you would like or any additional comments?

To offer you an accurate quote in one of Mid-Alliance Insurance Associates' underwriting companies, Mid-Alliance Insurance will collect information from consumer reporting agencies, such as driving record, claims, and credit history reports. Future reports may be used to update or renew your insurance.