UtahHealth.com

1. Email Required
2. First Name Required
3. Last Name Required
4. Address
5. City
6. State
7. Zip Code
8. Phone Required
9. Alternate Phone
10. Fax #
11. How should we contact? E-Mail Fax Regular Mail Call me by Phone

1. Insurance Carrier Name
2. Currently Insured? Yes No
3. How do you pay your premium? Monthly Every 3 months Every 6 months Every 12 months
4. Next Payment due date?
5. How much is your current premium (Approximate)?
6. Rate Your Credit History: Excellent Fair Poor Horrible

1. Vehicle #1 (Year, Make & Model)
2. VIN #1 (If available)
3. Vehicle #1 Pleasure Drive to work, 6-30 miles Drive to work, over 30 miles
4. Driver Name
5. Date of Birth
6. Marital Status Single Married Other
7. Driver Social Security No (Optional but recommended)

8. Residence Type Own Home Rent Live with Parents
9. Occupation
10. Driver`s License No
11. List Traffic Violations in last 3 years to the best of your knowledge
12. List/Describe Any Accidents
13. SR-22 Needed? Yes No

1. Vehicle #2 (Year, Make & Model)
2. VIN #2 (If available)
3. Vehicle #2 Pleasure Drive to work, 6-30 miles Drive to work, over 30 miles
4. Driver Name
5. Date of Birth
6. Marital Status Single Married Other
7. Driver Social Security No (Optional but recommended)

8. Residence Type Own Home Rent Live with Parents
9. Occupation
10. Driver`s License No
11. List Traffic Violations in last 3 years to best of your knowledge
12. List/Describe Any Accidents
13. SR-22 Needed? Yes No

1. Vehicle #3 (Year, Make & Model)
2. VIN #3 (If available)
3. Vehicle #3 Pleasure Drive to work, 6-30 miles Drive to work, over 30 miles
4. Driver Name
5. Date of Birth
6. Marital Status Single Married Other
7. Driver Social Security No (Optional but recommended)

8. Residence Type Own Home Rent Live with Parents
9. Occupation
10. Driver`s License No
11. List Traffic Violations in last 3 years to the best of your knowledge
12. List/Describe Any Accidents
13. SR-22 Needed? Yes No

1. Vehicle #4 (Year, Make & Model)
2. VIN #4 (If available)
3. Vehicle #4 Pleasure Drive to work, 6-30 miles Drive to work, over 30 miles
4. Driver Name
5. Date of Birth
6. Marital Status Single Married Other
7. Driver Social Security No (Optional but recommended)

8. Residence Type Own Home Rent Live with Parents
9. Occupation
10. Driver`s License No
11. List Traffic Violations in last 3 years to the best of your knowledge
12. List/Describe Any Accidents
13. SR-22 Needed? Yes No

1. Liability Coverage & Limits Select Liability Coverage $25,000/$50,000/$25,000 $50,000/$100,000/$50,000 $100,000/$300,000/$100,000 $250,000/$500,000/$100,000
2. Uninsured/Underinsured Motorist Select Uninsured/Underinsurance $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $100,000 Combined Limit $300,000 Combined Limit $500,000 Combined Limit
3. Uninsured Motorist Property Damage Select Uninsured Motorist $10,000 $25,000 $50,000

Comprehensive/Other Than Collision

1. Deductible Vehicle #1: Select Deductible Vehicle # $50 $100 $200 $500 $1000
2. Deductible Vehicle #2: Select Deductible Vehicle # $50 $100 $200 $500 $1000
3. Deductible Vehicle #3: Select Deductible Vehicle # $50 $100 $200 $500 $1000
4. Deductible Vehicle #4: Select Deductible Vehicle # $50 $100 $200 $500 $1000

Collision

1. Deductible Vehicle #2: Select Deductible Vehicle # $50 $100 $200 $500 $1000
2. Deductible Vehicle #2: Select Deductible Vehicle # $50 $100 $200 $500 $1000
3. Deductible Vehicle #4: Select Deductible Vehicle # $50 $100 $200 $500 $1000
4. Deductible Vehicle #4: Select Deductible Vehicle # $50 $100 $200 $500 $1000

Other

1. Towing Needed? Yes No
2. Rental Car Needed? Yes No
3. Additional Comments (eg. Good Student 3.0+ GPA, New Parent, additional vehicles or drivers)