Name:

Address:

Suite/Apt:

City: State: Zip:

Home Phone: Best time to call:

Work Phone: Best time to call:

Fax:

Email:

How would you like to be contacted? 

Email Phone Fax

Current Carrier Information 

What is the expiration date of your current automobile policy?

Who is your current auto insurance carrier (not agency)?

Vehicle Information 

List the vehicles currently insured and/or you want insured in your household.

Vehicle 1

Year: Make: Model:

Enter Vehicle Identification Number(VIN) if known:

Vehicle 2

Year: Make: Model:

Enter Vehicle Identification Number(VIN) if known:

Vehicle 3

Year: Make: Model:

Enter Vehicle Identification Number(VIN) if known:

Use of Vehicle 1 (required)

Pleasure Work > 3 miles Work < 3 miles Business 

Use of Vehicle 2 (if applicable)

N/A Pleasure Work > 3 miles Work < 3 miles Business 

Use of Vehicle 3 (if applicable)

N/A Pleasure Work > 3 miles Work < 3 miles Business 

Coverage Information 

Bodily Injury limits of liability:

SELECT ONE PLEASE. 50,000 100,000 300,000 500,000 

Property Damage limits of liability:

SELECT ONE PLEASE. 25,000 50,000 100,000 

Medical Payments:

Yes No

Uninsured Motorist:

Yes No

Comprehensive (Fire, Theft, Vandalism, etc) Coverage Option:

Yes No  : If Yes, please select deductible: SELECT ONE PLEASE. No Coverage Desired 250 500 1000 

Collision Coverage Option:

Yes No  : If Yes, please select deductible: SELECT ONE PLEASE. No Coverage Desired 250 500 1000 

Do you have any other special coverages:(Towing,Special Equipment,etc.)

Do you have any special discounts:(Alarm,Airbag,Nonsmoker,etc.)

Driver Information 

List all licensed drivers in your household?

Driver 1

Name: Birthdate: 

Sex: ???? Male Female Marital Status: ???? Married Single Divorced Widowed 

Drivers License #:

Driver 2 (If applicable)

Name: Birthdate: 

Sex: NA Male Female Marital Status: NA Married Single Divorced Widowed 

Drivers License #:

Driver 3 (if applicable)

Name: Birthdate: 

Sex: NA Male Female Marital Status: NA Married Single Divorced Widowed 

Drivers License #:

Does any driver require a financial responsibility filing?

Yes No:   If Yes, which driver(s)? 

Are there any drivers with less than 5 years experience? ( Exception: youthful operators on their parents policy.)

Yes No:    If Yes, which driver(s)? 

List all accidents or violations for all license operators?

Driver 1

Violation Date: Violation Code: NONE Speeding < 25MPH Speeding 25MPH or more At-fault accident Drag Racing Felony involving vehicle Hit and Run or failure to stop at scene of accident Homicide or manslaughter involving vehicle Driving w/ revoked or suspended licience Eluding police officer Failure to take blood or breath test Reckless Driving Driving under the influence Failure to yield Disregarding a traffic light Operating w/o owner consent Open bottle violation Illegal trans of alcohol Inexperienced operator (< 1yr) Unverifible driving record other Not listed 

Driver 2 (if applicable)

Violation Date: Violation Code: NONE Speeding < 25MPH Speeding 25MPH or more At-fault accident Drag Racing Felony involving vehicle Hit and Run or failure to stop at scene of accident Homicide or manslaughter involving vehicle Driving w/ revoked or suspended licience Eluding police officer Failure to take blood or breath test Reckless Driving Driving under the influence Failure to yield Disregarding a traffic light Operating w/o owner consent Open bottle violation Illegal trans of alcohol Inexperienced operator (< 1yr) Unverifible driving record other Not listed 

Driver 3 (if applicable)

Violation Date: Violation Code: NONE Speeding < 25MPH Speeding 25MPH or more At-fault accident Drag Racing Felony involving vehicle Hit and Run or failure to stop at scene of accident Homicide or manslaughter involving vehicle Driving w/ revoked or suspended licience Eluding police officer Failure to take blood or breath test Reckless Driving Driving under the influence Failure to yield Disregarding a traffic light Operating w/o owner consent Open bottle violation Illegal trans of alcohol Inexperienced operator (< 1yr) Unverifible driving record other Not listed 

Please press SUBMIT REQUEST when finished filling out the necessary form areas. 

Your request will be processed as soon as it is received. THANK YOU .

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.For More Information Contact:

Shannon Agency
400 Massasoit Avenue East Providence, Rhode Island 02914
Tel: (401) 431-0065
FAX: ((401) 438-0877
Internet: shannonagency.com

Copyright © 1999 Shannon Agency
Last modified: June 6, 1999