Classic Auto Insurance Form | Jim Kelly & Associates

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Alternate Phone

Email(Required)

Date of Birth(Required)

Marital Status(Required)

Gender(Required)

Own or Rent Home

Currently Insured

If no, when did you last have insurance?

Current Carrier

How did you hear about us?

Coverage Options

Bodily Injury Liability(Required)

Property Damage Liability(Required)

Uninsured Motorist Bodily Injury

Uninsured Motorist Property Damage

Underinsured Motorist Bodily Injury

Medical Pay / PIP

Vehicle Information

Vehicles

Vehicle (Year/Make/Model)(Required)

VIN Number

Annual Mileage

Drive to Work or School

Number of Miles (One Way)

Days Per Week

Comprehensive Deductible

Collision Deductible

Towing

Rental

Driver Information

Drivers

Name(Required)

First Last

Vehicle Used(Required)

Relationship(Required)

Gender(Required)

Marital Status(Required)

Date of Birth(Required)

Percent Use

Driver License Number

State Issued

SR22 Required

Violations

Drivers

Violation Type

Driver

Date Occurred

Additional Information

Bodily Injury/Property Damage/Both