A Professional Agency with Personal Service

Insurance Programs
At Heritage Insurance Group, Inc., we offer you a wide variety of personal lines products including but not limited to:
 
  Auto
  Boat/Yacht
  Dwelling Fire
  Homeowners
  Life Insurance
  Personal Articles
  Umbrella
  Wedding


Request an insurance quote online!

Auto  |  Homeowners  |  Life

Auto Insurance Application

 
Full Name:  
Address:
City:
Zip Code:
   
Email address:
Phone (Home): ex. xxx-xxx-xxxx
Phone (Work):
Cell Phone:
 
Present auto carrier:

Expiration date:

ex. xx/xx/xxxx

   
Do you:

Any coverage declined, cancelled, or not renewed in past 3 years?  Yes  No

How are vehicles titled?

 

 

Personal Information:

 
Driver1:
Date of Birth: ex. xx/xx/xxxx
Driver's License No.:
Social Security No.: ex. xxx-xx-xxxx
 
Driver2:
Date of Birth: ex. xx/xx/xxxx
Driver's License No.:
Social Security No.: ex. xxx-xx-xxxx
   
Driver3:
Date of Birth: ex. xx/xx/xxxx
Driver's License No.:
Social Security No.: ex. xxx-xx-xxxx
   
Driver4:
Date of Birth: ex. xx/xx/xxxx
Driver's License No.:
Social Security No.: ex. xxx-xx-xxxx
   

Does any driver qualify for driver training credit? Yes  No (If yes, need certificate)

Any household members in military service? Yes  No (If yes, need details)

Any cars kept at school? Yes  No

 

Vehicle Information:

Vehicle 1: Year Make
Model

VIN #:

Primary Driver:

Vehicle used for:


Lienholder? Yes No

Anti-theft discounts: Audio alarm Manual set device Auto set device

 

Vehicle 2: Year Make
Model

VIN #:

Primary Driver:

Vehicle used for:


Lienholder? Yes No

Anti-theft discounts: Audio alarm Manual set device Auto set device

 

Vehicle Information:

Vehicle 3: Year Make
Model

VIN #:

Primary Driver:

Vehicle used for:


Lienholder? Yes No

Anti-theft discounts: Audio alarm Manual set device Auto set device

 

Vehicle 4: Year Make
Model

VIN #:

Primary Driver:

Vehicle used for:


Lienholder? Yes No

Anti-theft discounts: Audio alarm Manual set device Auto set device

 

Coverages: Full Tort Limited Tort

Liability limits: 50/100 100/300 250/500 500/500 Other

Property damage: 15% 25% 50% 100%

UM UIM

Income loss: None 5000 15000 25000 50000

Funeral: None 1500 2500

Accidental Death: None 5000 10000 25000

Medical: None 5000 10000 25000 50000 100000

Comprehensive: ACV 250 500 1000 CAR#

Collision: 250 500 1000 CAR#

Gap coverage?:

Comments or Questions?:


 

Heritage Insurance Group, Inc.

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4101 Tilghman Street  Allentown, PA. 18104
Phone: 610-398-1535     Fax: 610-398-3301

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