| *Name: |
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| *Email address or phone number: |
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| *Are you a member of Indiana Members Credit Union? |
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| *Address (with County): |
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| *Married or Single |
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| *Own/Rent/Other |
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| Driver Information: |
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| *Driver 1 Name (same as above): |
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| *Date of Birth: |
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| Driver 2 Name: |
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| Date of Birth: |
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| Driver 3 Name : |
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| Date of Birth: |
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| Driver 4 Name: |
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| Date of Birth: |
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| Current Insurance Company (if applicable): |
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| Date of renewal or lapse: | |
Vehicles: List Year, Make and Model
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| *Vehicle 1: |
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| Vehicle 2: | |
| Vehicle 3: | |
| Vehicle 4: | |
*Current liability limits:
(UM/UIM limits will be quoted to match the above BI/Liability limits) |
25/50
50/100
100/300
250/500 |
| *Property damage limit 25, 50 or 100: | |
Deductible/Other coverages: |
| Vehicle 1: |
Comp
Collision
Tow?
Rental?
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| Vehicle 2: |
Comp
Collision
Tow?
Rental?
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| Vehicle 3: |
Comp
Collision
Tow?
Rental?
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| Vehicle 4: |
Comp
Collision
Tow?
Rental?
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| *Miles driven to work or school: |
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
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Any accidents or claims, regardless of fault (hit a deer, got rear-ended, etc.)
or violations for
any driver in the last 5 years?
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| Driver 1: |
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| Driver 2: |
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| Driver 3: |
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| Driver 4: |
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| Discounts: (Choose the ones that apply to you) |
ABS
AntiTheft
Good Student
Driver's ED
Clean Driver
Auto & Home |
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| Section 2 - Home Information |
| *Year home was built: |
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| *How many stories is your home: |
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| *Exterior of home: |
Brick
Frame
Vinyl
Other |
| *Square footage: |
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| *Number of bedrooms |
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| *Full or half bathroom: |
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| *Please check the following that apply: |
Living Room
Dining Room
Front Room
Basement
Slab
Crawl Space |
| *Do you have a 1, 2, 3, or 4 car garage: |
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| *Is your garage attached or detached: |
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| *Is the garage Brick, Frame, Vinyl or Block: |
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| *Select the following if they apply to your home: |
Fireplace
Woodstove
Swimming Pool
Trampoline |
| If your home is over 15 years old, please indicate updates: |
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Electrical type: |
Fuse
Circuit Breaker
Year it was updated:
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| Furnace: |
Gas
Electric
Other
Year it was updated:
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| Roof: |
Shingle
Slate
Metal
Other
Year it was updated:
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| *Replacement value of (or amount to rebuild) your home: |
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| *Deductible amount for quote: |
$250
$500
$1,000
$2,500
(Wind & hail claims are $1,000 deductible) |
| Current insurance carrier (if applicable): |
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| *Have there been any claims or losses on the home in the last 5 years: |
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| If so, list type, date and amount paid: |
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| *Do you have any pets? If so, please list type: |
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| Bite history: |
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| *Do you have an alarm system? If so, is it direct reporting or monitored: |
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| The following are optional coverages. Please select the ones you may be interested in: |
Back up of sewer & drain (covers damage caused by water from a drain or sump pump that backs up into the home) A must for homes with basements.
Earthquake (this adds back the exclusion of this coverage.)
Scheduled property such as jewelry, furs, art work, musical instruments
Recreational vehicle coverage such as snowmobile, 4-wheeler or jet ski |
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