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  1. Automotive Insurance Quote Form

  2. Insured (Name)
    Invalid Input
  3. Email(*)
    Please input a valid email address
  4. Mailing Address (City, State, Zip)
    Invalid Input
  5. Garaging Address
    Invalid Input
  6. Home Phone
    Invalid Input
  7. Work Phone
    Invalid Input
  8. Employment Agency
    Invalid Input
  9. Date Employed by State
    Invalid Input
     Please use MM/DD/YYYY format
  10. Occupation
    Invalid Input
  11. Type of Residence
    Invalid Input
  12. Other (Explain)
    Invalid Input
  13. Prior or present insurance carrier
    Invalid Input
  14. How long policy in force
    Invalid Input
  15. Expiration date on policy
    Invalid Input
     Please use MM/DD/YYYY format

  16. Other Named Insured (Lien Holder)
  17. Name
    Invalid Input
  18. Address (Street, City, State, Zip Code)
    Invalid Input
  19. Other SafeCo Products
    Invalid Input

  20. Drivers (Each Person In Household)
  21. Driver 1 First Name
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  22. Driver 1 Last Name
    Invalid Input
  23. Driver 1 Social Security #
    Invalid Input
  24. Driver 1 Veh # Driven
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  25. Driver 2 First Name
    Invalid Input
  26. Driver 2 Last Name
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  27. Driver 2 Social Security #
    Invalid Input
  28. Driver 2 Veh # Driven
    Invalid Input
  29. Driver 3 First Name
    Invalid Input
  30. Driver 3 Last Name
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  31. Driver 3 Social Security #
    Invalid Input
  32. Driver 3 Veh # Driven
    Invalid Input
  33. Driver 4 First Name
    Invalid Input
  34. Driver 4 Last Name
    Invalid Input
  35. Driver 4 Social Security #
    Invalid Input
  36. Driver 4 Veh # Driven
    Invalid Input

  37. Information on Each Driver on Policy
  38. Driver 1 Date of Birth
    Invalid Input
     Please use MM/DD/YYYY format
  39. Driver 2 Date of Birth
    Invalid Input
     Please use MM/DD/YYYY format
  40. Driver 3 Date of Birth
    Invalid Input
     Please use MM/DD/YYYY format
  41. Driver 4 Date of Birth
    Invalid Input
     Please use MM/DD/YYYY format
  42. Driver 1 Gender
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  43. Driver 2 Gender
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  44. Driver 3 Gender
    Invalid Input
  45. Driver 4 Gender
    Invalid Input
  46. Driver 1 Marital Status
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  47. Driver 2 Marital Status
    Invalid Input
  48. Driver 3 Marital Status
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  49. Driver 4 Marital Status
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  50. *Types of Discounts: A.) Good Student ("B" or better - 3.0) B.) Accident Prevention Course (55 or older) C.) Distant Student (More than 100 miles away)
  51. Driver 1 Driver's License Suspended or Revoked in the Last 5 Years?
    Invalid Input
  52. Driver 2 Driver's License Suspended or Revoked in the Last 5 Years?
    Invalid Input
  53. Driver 1 Driver's License Suspended or Revoked in the Last 5 Years?
    Invalid Input
  54. Driver 4 Driver's License Suspended or Revoked in the Last 5 Years?
    Invalid Input
  55. Driver 1 SR22 Filing?
    Invalid Input
  56. Driver 2 SR22 Filing?
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  57. Driver 3 SR22 Filing?
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  58. Driver 4 SR22 Filing?
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  59. If "yes" to SR22 filing: Filing date
    Invalid Input
  60. Driver 2 If "yes" to SR22 filing: Filing date
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  61. Driver 3 If "yes" to SR22 filing: Filing date
    Invalid Input
  62. Driver 4 If "yes" to SR22 filing: Filing date
    Invalid Input
  63. Driver 1 If "yes" to SR22 filing: End date
    Invalid Input
  64. Driver 2 If "yes" to SR22 filing: End date
    Invalid Input
  65. Driver 3 If "yes" to SR22 filing: End date
    Invalid Input
  66. Driver 4 If "yes" to SR22 filing: End date
    Invalid Input

  67. Any reportable incidents in the last five (5) years
    *Types of reportable incidents: A.) Violation B.) At-fault accident c.) Not-at-fault D.) Comprehensive
  68. Driver 1 Type of incident*
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  69. Driver 2 Type of incident*
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  70. Driver 3 Type of incident*
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  71. Driver 4 Type of incident*
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  72. Driver 1 Date of incident
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  73. Driver 2 Date of incident
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  74. Driver 3 Date of incident
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  75. Driver 4 Date of incident
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  76. Driver 1 Bodily Injury Paid
    Invalid Input
  77. Driver 2 Bodily Injury Paid
    Invalid Input
  78. Driver 3 Bodily Injury Paid
    Invalid Input
  79. Driver 4 Bodily Injury Paid
    Invalid Input
  80. Driver 1 Comp or Call Paid
    Invalid Input
  81. Driver 2 Comp or Call Paid
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  82. Driver 3 Comp or Call Paid
    Invalid Input
  83. Driver 4 Comp or Call Paid
    Invalid Input
  84. Driver 1 Remarks About Incident
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  85. Driver 2 Remarks About Incident
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  86. Driver 3 Remarks About Incident
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  87. Driver 4 Remarks About Incident
    Invalid Input
  88. Driver 1 Driver's License Number
    Invalid Input
  89. Driver 2 Driver's License Number
    Invalid Input
  90. Driver 3 Driver's License Number
    Invalid Input
  91. Driver 4 Driver's License Number
    Invalid Input
  92. Driver 1 State Where DL Was Issued
    Invalid Input
  93. Driver 2 State Where DL Was Issued
    Invalid Input
  94. Driver 3 State Where DL Was Issued
    Invalid Input
  95. Driver 4 State Where DL Was Issued
    Invalid Input
  96. Driver 1 Age Received First DL
    Invalid Input
  97. Driver 2 Age Received First DL
    Invalid Input
  98. Driver 3 Age Received First DL
    Invalid Input
  99. Driver 4 Age Received First DL
    Invalid Input

  100. Vehicle Information
  101. Vehicle 1 VIN#
    Invalid Input
  102. Vehicle 2 VIN#
    Invalid Input
  103. Vehicle 3 VIN#
    Invalid Input
  104. Vehicle 4 VIN#
    Invalid Input
  105. Vehicle 1 Year
    Invalid Input
  106. Vehicle 2 Year
    Invalid Input
  107. Vehicle 3 Year
    Invalid Input
  108. Vehicle 4 Year
    Invalid Input
  109. Vehicle 1 Make
    Invalid Input
  110. Vehicle 2 Make
    Invalid Input
  111. Vehicle 3 Make
    Invalid Input
  112. Vehicle 4 Make
    Invalid Input
  113. Vehicle 1 Model
    Invalid Input
  114. Vehicle 2 Model
    Invalid Input
  115. Vehicle 3 Model
    Invalid Input
  116. Vehicle 4 Model
    Invalid Input
  117. Vehicle 1 Use*
    Invalid Input
  118. Vehicle 2 Use*
    Invalid Input
  119. Vehicle 3 Use*
    Invalid Input
  120. Vehicle 4 Use*
    Invalid Input
  121. Vehicle 1 Miles One Way to Work or School
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  122. Vehicle 2 Miles One Way to Work or School
    Invalid Input
  123. Vehicle 3 Miles One Way to Work or School
    Invalid Input
  124. Vehicle 4 Miles One Way to Work or School
    Invalid Input
  125. Vehicle 1 Days Per Week
    Invalid Input
  126. Vehicle 2 Days Per Week
    Invalid Input
  127. Vehicle 3 Days Per Week
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  128. Vehicle 4 Days Per Week
    Invalid Input
  129. Vehicle 1 Anti-Theft**
    Invalid Input
  130. Vehicle 2 Anti-Theft**
    Invalid Input
  131. Vehicle 3 Anti-Theft**
    Invalid Input
  132. Vehicle 4 Anti-Theft**
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  133. Converage

    *Types of Vehicle Use: A.) Pleasure or Work/School (less than 4 miles) B.) Work/School (4 or more miles) C.) Business Use D.) Farm Use

    ** Types of Anti-Theft Devices: A.) Alarm Only B.) Active Disabling System C.) Passive Disabling System


  134. Liability Limits of Current Policy
    Invalid Input
  135. Liability - Bodily Injury Limits and Property Damage Limits
    Invalid Input
  136. Work Loss Coverage
    Invalid Input
  137. Accidental Death Benefits
    Invalid Input
  138. Medical Payments (Med Pay)
    Invalid Input
  139. Uninsured motorist bodily injury (UMBI) and property damage - Has to be sold in same limits as Bodily Injury and Property Damage unless reduced or rejected by the customer. If purchased on 1 car, it must be on all cars on the policy.
  140. Choose One:
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  141. Underinsured motorist bodily injury (UIMBI) - This coverage is required on all auto policies unless rejected by the customer. If purchased on 1 car, it must be on all cars on the policy.
  142. Choose One:
    Invalid Input
  143. Comprehensive Physical Damage Coverage (COMP) - COMP is available to be purchased separately and with differing deductibles per vehicle.
  144. Deductible - Vehicle
  145. NO COVERAGE
    Invalid Input
  146. 100
    Invalid Input
  147. 250
    Invalid Input
  148. 500
    Invalid Input
  149. 750
    Invalid Input
  150. 1,000
    Invalid Input
  151. 1.500
    Invalid Input
  152. 2,000
    Invalid Input
  153. Collision Physical Damage (COLL) - Same as above.
  154. Deductible - Vehicle
  155. NO COVERAGE
    Invalid Input
  156. 100
    Invalid Input
  157. 250
    Invalid Input
  158. 500
    Invalid Input
  159. 750
    Invalid Input
  160. 1,000
    Invalid Input
  161. 1,500
    Invalid Input
  162. 2,000
    Invalid Input
  163. Towing and Labor Costs - Can be provided on any vehicle insured for liability or property damage
    Invalid Input
  164. *To receive this coverage you must purchase comp and $50.00 a day loss of use
  165. Loss of Use
    Invalid Input
  166. Special Equipment - Must be listed on application
  167. Invalid Input
  168. The State Employees Benefit Corporation customarily receives compensation from the insurance companies whose products we offer in the form of commissions, which consist of a percentage of the premium collected by the insurers. The Corporation may also receive additional compensation from some of our insurers based on volume, profitability, and other factors.

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