| Please
fill out information on form as completely as possible for the state
of Kentucky. The Lancaster Agency is authorized
only to write insurance in the state Kentucky. If you have any questions
about this form or making a claim, please contact
us. |
|
Personal
Information
|
| Name
(first, middle, last) : |
|
| Address
line 1: |
|
| Address
line 2: |
|
| Address
(city, state, zip code) : |
|
| E-mail: |
|
Social
Security # (required): |
|
| Home
Phone: |
|
Work
Phone: |
|
| Fax: |
|
Best
time to call: |
|
|
Vehicle
Info
|
| Year:
|
|
Make: |
|
| Model: |
|
Vehicle
I.D. #: |
|
| Annual
Mileage: |
|
| Air
Bag or electric seatbelt? |
|
Anti-theft
device?
|
|
|
Driver
Information
|
| Years
of driving experience: |
|
Driver
training? |
|
| Please
list all tickets and/or accidents in the last six years, or SDIP step
if known: |
|
| Please
list dates of birth and drivers license #'s for all operators (primary
driver required: |
Date
of Birth (list primary first - required): |
Drivers
License # (list primary first - required): |
|
|
|
Secondary
|
|
|
|
Additional
Driver3
|
|
|
|
Additional
Driver4
|
|
|
|
Coverage
Options:
|
| Part
1 - Bodily Injury to others: |
* SL - Single Limit |
| Part
2 - Property damage: |
|
| Part
3 - Personal Injury Protection: |
|
| Part
4 - Uninsured Motorist: |
|
| Part
5 - Underinsured Motorist: |
|
| Part
6 - Optional Bodily Injury: |
|
| Part
7 - Comprehensive (deductible): |
|
| Part
8 - Collision (deductible): |
|
| Part
8 - Limited Collision: |
|
| Part
11 - Towing and Labor: |
|
|
|
|
| |
Please note that submitting an insurance quotation request to
The Lancaster Agency does not constitute a binding confirmation of new or
altered insurance coverage. Written confirmation must be obtained
from The Lancaster Agency to confirm binding or altering coverage.
|
