Auto Insurance Quote Form
Pennsylvania Only

To receive a quote, please fill out the form below.....

Name:     Social Security #: 
Address:
City:  State:   Zipcode: 
Phone Numbers:
E-Mail Address:
Do you belong to any of these groups?

Current Carrier Information and Expiration date of policy?
Your Current Insurance Company Name:  Policy Expiration date: 


Tort Option:   "Limited" Tort limits your ability to sue, "Full" Tort does not.

Liability Limits
Bodily Injury Limit / or Single Limit per Accident Property Damage Limit

Un and Underinsured Motorist Coverage
Limit Option: Stacked / Non-Stacked

Pennsylvania First Party Benefits
Please select either Selected First Party Benefits or Combined Benefits

S E L E C T E D   F I R S T   P A R T Y   B E N E F I T S

Medical Expenses Extraordinary Medical Expenses
(Medical Expenses from $100,001 to....)		 Work Loss Benefits Funeral Expenses Accidental Death Benefits

OR

C O M B I N E D   F I R S T   P A R T Y   B E N E F I T S

Per Person Limit: (Medical Expenses & Work Loss Benefits/Funeral Expenses/Accident Death Benefit)
    Do you need Work Loss Benefits? 

VEHICLE INFORMATION
Year Make Model Vehicle Identification # Usage Annual
Mileage		 Comprehensive
Ded		 Collision
Ded		 Towing
Amount		 Rental/Day
Amount
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Vehicle 5
Vehicle 6


DRIVER INFORMATION
Driver Name Birth Years
Licensed		 Sex Marital
Status		 License # Occupation * Defensive
Driving
Course or Driver
Training
Course
In the last 3 years		 If student, QPA
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
* Occupation is now needed: Insurance companies are now asking for the driver's occupation because they are now using it in the rating structure


ACCIDENTS & VIOLATIONS Please list ALL accidents and violations within last 3 years......
DATE DRIVER NAME TYPE OF OCCURRENCE


GENERAL INFORMATION
Where do you live?
Any unrepaired damage to any vehicle of $ 200 or more?
How many years have you been with your existing insurance company?
Are you a member of AAA? Yes
No
(After you Submit) For better auto rates, please quote my HOMEOWNERS/RENTERS INSURANCE

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M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474           Fax: (724) 327-7911
Toll Free: 1-800-977-2999      Fax: 1-888-800-0034