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Contact Information

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State     Zip:
Phone
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Current Policy Information
Policy Expiration Date
Premium Amount:
How often is this paid?

Vehicle #1 Information

Year:
Make:

Model:

Estimated Annual Mileage:
Business Use: Yes  No
Leased: Yes  No
Vehicle Features (check all below that apply to your vehicle)
Airbags Yes  No
Alarm Yes  No
Automatic Seatbelts Yes  No
Window Etching Yes  No
Coverages  
Optional Bodily Injury    other
Property Damage    other
Uninsured Motorist    other
Underinsured Motorist    other
Medical Payments
Rental Coverage
Towing
Deductibles  
Comprehensive Deductible    other
Collision Deductible    other
Driver Information (name all drivers)
  Driver #1
Full Name
Date of Birth
License Number
  Driver #2
Full Name
Date of Birth
License Number

Vehicle #2 Information

Year:
Make:

Model:

Estimated Annual Mileage:
Business Use: Yes  No
Leased: Yes  No
Vehicle Features (check all below that apply to your vehicle)
Airbags Yes  No
Alarm Yes  No
Automatic Seatbelts Yes  No
Window Etching Yes  No
Coverages  
Optional Bodily Injury    other
Property Damage    other
Uninsured Motorist    other
Underinsured Motorist    other
Medical Payments
Rental Coverage
Towing
Deductibles  
Comprehensive Deductible    other
Collision Deductible    other
Driver Information (name all drivers)
  Driver #1
Full Name
Date of Birth
License Number
  Driver #2
Full Name
Date of Birth
License Number
Additional Comments  
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97 Center Street, Chicopee, Massachusetts 01013  •  phone 413-594-5984  •  fax 413-592-1142
Copyright Phillips Insurance Agency, Inc. 2004