The Chalmers Group: Get A Quote


				home \| locations \| contact \| site map

ABOUT	KNOWLEDGE	PRODUCTS	GET A QUOTE	CLAIMS

Maine or New Hampshire Personal Auto, Boat, Motorcycle,
ATV, RV or Snowmobile Quote Form*

Please check the Chalmers Group location nearest you. After you have completed and submitted this information we will contact you.

Maine Offices:
Chalmers Insurance Agency, Bridgton, ME
C.E. Carll Agency, Gorham, ME
C.E. Carll Agency, Standish, ME
Lovejoy & Wadsworth Agency, Parsonsfield, ME
Pike Insurance Agency, Fryeburg, ME

New Hampshire Offices:
Ossipee Insurance Agency, Center Ossipee, NH
Palmer & Pike Conway Dahl, North Conway, NH

BASIC INFORMATION Please answer to following 20 questions and submit.

1.	Your Full Name:
	Date of Birth:
	Driver's License #:
	State Licensed:
	Occupation:
	List any accidents or violations within the past 5 years:

2.	Mailing Address/Street:
	City:
	State:
	Zip:

	Home Phone:
	Cell Phone:
	Work Phone:
	Email Address:

3.	Garaging or Storage Location (if different from mailing address)
	Street:
	City:
	State:
	Zip:

4.	Spouse or Co-Insured's Name:
	Date of Birth:
	Social Security #:
	Driver's License #:
	State Licensed:
	Occupation:
	Relationship To Insured:
	List any accidents or violations within the past 5 years:

5. Information Disclosure
in order to provide a competitive and accurate quote we may order consumer reports, including, but not limited to: credit scores, insurance scores, claims reports and driving records. This is standard practice for all insurance companies. I have read the disclosure and would like to continue: Yes No

COVERAGE INFORMATION

1. Name of your current insurance company:
    Years with that company:

2. Do you own your own home? Yes    No

3. Bodily Injury and Property Damage Limits (We will quote with Uninsured Motorists limits matching the Bodily Injury Limits):
$100/300/50 ($100,000 per person/$300,000 per accident bodily injury with $50,000 property damage)
$100/300/100
$250/500/100
$300,000 combined single limit liability covering bodily injury and property damage
$500,000 combined single limit liability

4. Medical Payment Per Person Per Accident:
$2,000              $5,000              $10,000              Other

VEHICLE INFORMATION: List the vehicles that you own and skip to the bottom to submit.

1. Vehicle #1:

Year: Make: Model: VIN#

Type of vehicle**:
Auto     Watercraft     Motorcycle     ATV     Snowmobile     RV     Trailer
State where vehicle is (or will be registered):

Is the vehicle registered to you and/or your spouse? Yes      No

If not, who is vehicle registered to:

Primary operator of this vehicle:

Annual Mileage:

Use: Commute to work less than 15 miles away.
Commute more than 15 miles.
Pleasure use only.
Business use.

Coverage on this vehicle (check all that apply): ONLY Comprehensive Coverage; vehicle is in storage, I do not drive it
Liability ONLY with no physical damage coverage
Full Coverage
Comprehensive Deductible:
         No comprehensive coverage
         $100          $250          $500
Collision Deductible:
         No collision coverage
         $250          $500          $1,000
Towing:
         No towing coverage
         $50 per towing          $75 per towing
Rental Reimbursement:
         No rental coverage
         $20 per day for a maximum of $600
        $30 per day for a maximum of $900
Auto Loan/Lease Coverage; my vehicle is financed.

** If this vehicle is a Motorcycle, Snowmobile, or ATV, we must also have the following information:

CCs: Value:

** If this vehicle is a Boat, we must also have the following information:

Length of boat: Maximum speed of boat:

Value of boat (separate from value of motor unless it is an inboard):

Boat motor type:         Outboard         In/Outboard         Inboard         Jet Drive

Year of motor: Make of Motor:

HP: Value of Motor:

** If this vehicle is a Trailer, we must also have the following information:

Type of trailer:         Utility         Snowmobile         Boat        Camper

Value: Length:

(Add another vehicle)

PLEASE LIST ALL OPERATORS IN YOUR HOUSEHOLD (other than yourself and your spouse listed above):

1.	Check either statement below if it applies: No other operators in the household. Other operators in household with their own policies (I will provide a copy of these policies).
2.	Driver's Name:
	Date of Birth:	Male Female
	Driver's License #:
	State Licensed:
	If under 21 on parent's policy: Driver's Training Good Student (B average or above)
	List any accidents or violations within the past 5 years:

(Add Another Driver)

20. Other comments:

*This is for quoting purposes only. No coverage can be bound or changed using this system. Completion of this form does not provide coverage. There is no coverage until you have paid the premium deposit and signed the application.

	Home \| The Chalmers Difference \| Principals \| Careers \| Companies \| Knowledge \| Products \| Personal Insurance \| Business Coverage Life & Health/Financial Services \| Specialty Products \| CAMPUSA \| Get A Quote \| Claims \| Locations \| Contact \| Site Map \| Privacy Policy
	© 2008 The Chalmers Group. All rights reserved.