Effective Date:
Your Name:
Your Mailing Address: Street

City                                                         State        Zip
     
E-mail Address:
Daytime Phone #:
Choose One: Please call me with quote premium.
Please send quote via e-mail.
Current coverage: Company:                                       Expiration Date:
 
Liability Limits and Coverages:
Please select the coverages and limits that are to apply to your vehicles. zA 1S2
Bodily Injury - Split Limits
Bodily Injury - Combined Limits
Property Damage
 Medical Payments
Uninsured Motorists


Underinsured Motorists
Enter additional information/comments here:
Your Vehicles:   If you have more than four vehicles, please call our office for a quote.

Vehicle 1.
Year          Make and model:
 
VIN (if known):

Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
Towing and Labor
Rental Reimbursement
Loan Lease Gap
Vehicle 2.
Year          Make and model:
 
VIN (if known):

Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
Towing and Labor
Rental Reimbursement
Loan Lease Gap
Vehicle 3.
Year          Make and model:
 
VIN (if known):

Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
Towing and Labor
Rental Reimbursement
Loan Lease Gap
Vehicle 4.
Year          Make and model:
 
VIN (if known):

Passive Restraint:
Vehicle Use
Miles to work/school
Comprehensive
Collision
Optional Coverages: Check all that apply.
Towing and Labor
Rental Reimbursement
Loan Lease Gap
Driver Information:   If there are more than four drivers, please call our office for a quote.

Driver 1:
Name:

DOB:                  Sex:      Marital Status
        
Driver 1 Occupation:

Social Security No:   -or-   Drivers License No:
  
Has Driver 1 had any accidents or violations
in the past 3 years?  If yes, please explain below:

Good Student Discount (3.0 ave. or better)
At School over 100 miles away.
 Driver 2:
Name:

DOB:                  Sex:      Marital Status
        
Driver 2 Occupation:

Social Security No:   -or-   Drivers License No:
  
Has Driver 2 had any accidents or violations
in the past 3 years?  If yes, please explain below:

Good Student Discount (3.0 ave. or better)
At School over 100 miles away.
Driver 3:
Name:

DOB:                  Sex:      Marital Status
        
Driver 3 Occupation:

Social Security No:   -or-   Drivers License No:
  
Has Driver 3 had any accidents or violations
in the past 3 years?  If yes, please explain below:

Good Student Discount (3.0 ave. or better)
At School over 100 miles away.
 Driver 4:
Name:

DOB:                  Sex:      Marital Status
        
Driver 4 Occupation:

Social Security No:   -or-   Drivers License No:
  
Has Driver 4 had any accidents or violations
in the past 3 years?  If yes, please explain below:

Good Student Discount (3.0 ave. or better)
At School over 100 miles away.
All Drivers:
If a Group Association Discount applies, please enter association below.


 What is the current occupation of your household's highest wage earner?
Please use the box below to enter any additional information you feel should be considered:
        
myagent@veenstrainsurance.com
Local: (248)553-3000 . Toll free: (800)445-6554 . Fax: (248) 553-8482
31700 W. 12 Mile Road . Suite 200 . Farmington Hills . Michigan . 48334-4461