Insured Information
Contact Name
Address
City
State
Zip
County
Email*
Home Phone Number
Date of Birth
Which local agency would you like to use?*
Please choose one. . . Gosline-Murchie Agency, Gardiner, ME Quirion Insurance Agency, Augusta, ME Pease Insurance Agency, West Rockport Vannah Insurance Agency, Waldoboro, ME Readfield Insurance Agency, Readfield, ME Richmond Insurance Agency, Richmond, ME Kristie Rowell Insurance Services, Hallowell, ME Cornerstone FInancial, Inc., ME RD Johnson Agency, Bethel, ME Erickson Bonding & Insurance Associates, Inc., Augusta, ME
1.
How many motorized vehicles licensed for road use are owned, leased, or regularly operated by you or any member of your household?
0-3 4 5-6
2.
How many residential properties are owned or rented by you or any member of your household?
0-1 2-4 5-6
3.
How many watercraft, other than jet skis and waverunners, are owned or regularly operated by you or any member of your household?
0 1-2 3
4.
How many jet skis and/or waverunners are owned or regularly operated by you or any member of your household?
5.
What is the number of drivers?
0-2 3-6
6.
How many drivers are under the age of 22?
0 1-2 3-4
7.
How many drivers are age 70 and over?
0 1-4
8.
How many moving violations have all drivers had within the last 3 years?
9.
How many at fault accidents have all drivers had within the last 3 years?
0 1 2
10.
Have you or any other driver been licensed to drive less than one year, currently have a learner's permit, and/or have a non-U.S. driver's license?
Yes No
11.
Have you or any other driver had a citation/conviction for driving under the influence of alcohol or drugs, reckless driving, careless driving, or negligent driving and/or had a driver's license suspended, revoked or refused in the last 5 years?
12.
Has any one driver had more than 3 moving violations in the last 3 years?
13.
Has any driver under the age of 22 had more than one driving incident within the last three years? (Incident means an at fault accident or moving violation.)
14.
Do you or any member of your household own or lease timberland, or land which is farmed, in excess of 640 acres, for which the liability coverage is provided by either a Homeowners, Farmowners, or Farm Comprehensive Personal Liability Policy (including partial ownership)?
15.
Do you or any member of your household have an occupation of a professional entertainer or athlete, media personality, state or federal political figure or any elected public official?
16.
Have you or any member of your household had any personal liability or personal auto bodily injury liability claims for which payment by your insurance company exceeded $25,000 in the last 5 years?
17.
Does any other member of your household or other person residing in your household have a Personal Umbrella policy?
Minimum Required Limits of Liability Please note that there are MINIMUM REQUIRED LIMITS OF LIABILITY and MINIMUM REQUIRED LIMITS OF AUTOMOBILE LIABILITY that you and ALL members of your household must agree to maintain during your policy period. Please check your current coverage to make sure that you qualify.
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