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Questions?
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Agent!

E-mail Questions to: jrumer@rumergroup.com

Toll-Free: 1-888-81-RUMER
Phone: 1-215-918-1882
Fax: 1-215-918-2220

Office Located at:
1432 Easton Road, #3-I
Warrington, PA 18976

On-Line Automobile Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name:
Street Address:
City:
State: (Must be Pennsylvania)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)

May We Call You To Obtain Your Social Security # for Maximim Discounts? (many of our carriers offer added discounts if we allow them to run a CLUE or Credit Report.)	Yes No

DRIVER INFORMATION #1

Name: Birthdate:

Sex (M/F): # Years U.S.
Licensing:

Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:

Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:

Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:

Does Driver need
an SR22 FILING? Yes No If YES to SR22 filing, why needed?
(list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)

Name: Birthdate:

Sex: # Years U.S.
Licensing:

Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:

Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:

Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:

Does Driver need
an SR22 FILING? Yes No Comments or
Remarks?

If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)

Year of vehicle: Make & Model:

Vehicle ID# (for rating accuracy):

Annual Mileage: Used in business?
(Explain, if yes):

VEHICLE #1 COVERAGES:

Limits of
Liability: $50/100 BI / 50 PD$100/300 BI / 100 PD $300,000 CSL $500,000 CSL

Comprehensive
Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Collision
Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Uninsured Motorists
Coverage? YES NO

Rental Car &
Towing Coverage? YES NO

Medical and/or
PIP Coverage? YES NO

VEHICLE #2 INFORMATION (if none, leave blank)

Year of vehicle: Make & Model:

Vehicle ID# (for rating accuracy):

Annual Mileage: Used in business?
(Explain, if yes):

VEHICLE #2 COVERAGES:

Limits of
Liability: $50/100 BI / 50 PD$100/300 BI / 100 PD $300,000 CSL $500,000 CSL

Comprehensive Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Collision
Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Uninsured Motorists
Coverage? YES NO

Rental Car &
Towing Coverage? YES NO

Medical and/or
PIP Coverage? YES NO

Do You Want the "Limited Tort" option quoted?
(Under the "Limited Tort' option, you & family members' right to seek financial compensation for injuries caused by other drivers are limited. You cannot sue for pain and suffering unless you sustain a serious or permanent injury, court defined as a "serious impairment of a bodily function".) Full Tort Option
(Under the "Full Tort" option, you maintain an unrestricted right for you and the members of your household to seek financial compensation for injuries caused by other drivers.)
Limited Tort Option
(Selection of the "Limited Tort" option will reduce your insurance premium but also reduce available benefits.)

If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:

Comments or Remarks:
(List additional drivers, autos, etc. here)

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Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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