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Maine Auto Insurance Application

Name:*

Business Name:

Address:*

City:*	State*:	Zip:*

Day Phone:*

Fax:

Email:*

Quote Information

Occupation:

Date of Birth:

Years Boating Experience:

Years Boat Owned:

Boating Courses/Licenses:

Any claims in last 5 years:

Occupation (s):

Year, Make and Model of Automobile (s):

Vehicle #1

Year: Make: Model:

Vehicle #2

Year: Make: Model:

Vehicle #3

Year: Make: Model:

Name and date of birth of all operators:

Operator #1

Name: Birth Date:

Operator #2

Name: Birth Date:

Operator #3

Name: Birth Date:

Limit of Liability:

Medical Payments:

Comprehensive Deductable:

Vehicle #1 Vehicle #2 Vehicle #3

Collision Deductable:

Vehicle #1 Vehicle #2 Vehicle #3

Towing / Labor Coverage: Yes No

Rental Reimbursement Coverage: Yes No

Driving History past three years:
Please include all accidents and violations for each operator, if none, please check "none."

Operator #1

NONE:

Operator #2

NONE:

Operator #3

NONE:

General Remarks:
Include how vehicles are used
(i.e. commute to work, # miles each way or pleasure use) and any other remarks.

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