FirstMark - Coverage Checklist Coverage Checklist - FirstMark Step 1 of 16 6% Writing Agent(Required)John ApplegateAndrew CowanDaniel FortuneRichard HarrisonAmanda SheaDavid TaylorRobert BalderasRosemary RamirezKenneth MeyerGail WelfringerGracia OlivasKirby WarrenScott WoosterErin CaseyJohn KorpiLaMia HayekLevi ChambersMichael DonnellyNolan WelfringerSaopon Cha'Bradley StampfliRiley McAuliffeClient Name First Last Policy(ies) Sold Auto Classic Auto Primary Home Secondary Home Condominium Owners Renter's Insurance Landlord's Policy Motorcycle Motorhome/RV Boat/Jet Ski ATV/Snowmobile Umbrella Life AutoBodily Injury Liability50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000Other - Not ListedUM/UIM50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000Other - Not ListedLiability Limits UM/UIM Limits PIP or Medical PIP Medical Excluded PIP Limit$10,000$35,000Medical Limit Total Drivers(Required)123456+Total Vehicles(Required)123456+Driver InformationPrimary Driver(Required) First Last Driver #2 First Last Driver #3 First Last Driver #4 First Last Driver #5 First Last Additional DriversFirst NameLast Name Add RemoveVehicle #1Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Vehicle #2Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Vehicle #3Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Vehicle #4Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Vehicle #5Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Classic AutoYearMake Model Insured Drivers Designated UsePleasureShows/EventsLiability same as primary auto coverage Yes No Classic Auto Liability Limits50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000Towing Included Excluded Trailer Included Excluded Modifications Included Excluded (Tint, Rims, Electronics)Please specify Photos or Appraisal Required? Yes No PIP or Medical Payments PIP Medical Payments Excluded PIP Limit$10,000$35,000Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No Coverage$0 Glass Deductible Included Excluded Stated Amount/Agreed Value Stated Value Agreed Value ValueSpare Parts Included Excluded Added to Umbrella Coverage Yes No Vehicle under restoration Yes No Primary HomeDeductible$500$1,000$1,500$2.500$5,000$10,000$25,0001%2%5%Mortgage/Escrow Yes No Earthquake Coverage Included Excluded Earthquake Deductible1%2%5%10%20%25%Landslide Coverage Included Excluded Landslide Deductible1%2%5%10%20%25%Extended Dwelling Limits Included Excluded Extended Dwelling ValueSpecial Personal Property Included Excluded Special Personal Property LimitLoss of Use/Additional Living Expenses Included Excluded Loss of Use/Additional Living Expenses Limit Extended Limits/Matching Roof & Siding Included Excluded Flood Included Excluded Water Backup Sewer and Drain Included Excluded Hidden Water Damage/Leak and Seepage Included Excluded Cyber Protection/ID Fraud Included Excluded Equipment Breakdown Coverage Included Excluded Service Line Enhancement Coverage Included Excluded Alarm System (fire and police) or Cameras Included Excluded Interior Sprinkler System Yes No Automatic Shut Off; water and/or gas Yes No Short-Term Rental (VRBO, AirBnb) Yes No Dog(s) Yes No Breed(s) Additional Animal(s) Yes No Please specify Does the property have a wood stove?YesNoTrampoline No Trampoline - With Net Trampoline - No Net Pool Pool - No Slide Pool - Has Slide No pool Golf Cart? Yes No Increased Limit - Jewelry Included Excluded Jewelry LimitIncluded ItemsIncreased Limit - Art (Agreed Value) Included Excluded Art LimitIncluded ItemsIncreased Limit - Firearms Yes No Firearms LimitIncluded ItemsIncreased Limit - Collections (Agreed Value) Included Excluded Collections LimitIncluded Items Secondary HomeDeductible$500$1,000$1,500$2.500$5,000$10,000$25,0001%2%5%Mortgage/Escrow Yes No Earthquake Coverage Included Excluded Earthquake Deductible1%2%5%10%20%25%Landslide Coverage Included Excluded Landslide Deductible1%2%5%10%20%25%Flood Coverage Included Excluded Short-Term Rental (VRBO, AirBnb) Yes No Water Backup Sewer and Drain Included Excluded Trampoline No Trampoline - With Net Trampoline - No Net Pool Pool - No Slide Pool - Has Slide No pool Does the property have a wood stove? Yes No Condominium InfoDeductibleMortgage/Escrow Yes No Interior Building Limit Included Excluded Interior Building Limit ValueSpecial Personal Property Included Excluded Special Personal Property LimitLoss of Use/Additional Living Expenses Included Excluded Loss of Use/Additional Living Expenses LimitLoss Assessments Included Excluded Master HOA Deductible Coverage Included Excluded Earthquake Coverage Included Excluded Flood Included Excluded Water Backup Sewer and Drain Included Excluded Hidden Water Damage/Leak and Seepage Included Excluded Cyber Protection/ID Fraud Included Excluded Equipment Breakdown Coverage Included Excluded Service Line Enhancement Coverage Included Excluded Alarm System (fire and police) or Cameras Yes No Interior Sprinkler System Yes No Automatic Shut Off; water and/or gas Yes No Short-Term Rental (VRBO, AirBnb) Yes No Dog(s) Yes No Breed(s) Additional Animal(s) Yes No Please specify Golf Cart? Yes No Does the property have a wood stove? Yes No Increased Limit - Jewelry (Theft) Yes No Jewelry LimitIncreased Limit - Art (Agreed Value) Yes No Art LimitIncreased Limit - Firearms (Theft) Yes No Firearms LimitIncreased Limit - Collections (Agreed Value) Yes No Collections Limit RentersPolicy Deductible Yes No DeductiblePersonal Property Yes No Personal PropertySpecial Personal Property Coverage Yes No Loss of Use/Additional Living Expenses Yes No Earthquake Coverage Included Excluded Cyber Protetion/ID Fraud Included Excluded Flood Included Excluded Water/Sewer Back Up Included Excluded Trampoline No Trampoline - With Net Trampoline - No Net Does the property have a wood stove? Yes No Pool Pool - No Slide Pool - Has Slide No pool Alarm System, Auto Shut Off/Sprinkler Yes No Dogs(s) Yes No Breed(s)Additional Animal(s) Yes No Please specify Increased Limit - Jewelry (Theft) Included Excluded Jewelry LimitIncreased Limit - Art (Agreed Value) Included Excluded Art LimitIncreased Limit - Firearms (Theft) Yes No Firearms LimitIncreased Limit - Collections (Agreed Value) Included Excluded Collections Limit LandlordProperty Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DeductibleMortgage present/Escrow Pay? Yes No Extended Limits - Dwelling Included Excluded Extended LimitsLandlords Contents (With Replacement Cost) Included Excluded Landlord ContentsExtended Limits/Matching - Roof And Siding Included Excluded Loss of Rents Included Excluded Earthquake Coverage Included Excluded Flood Included Excluded Water/Sewer Back up Included Excluded Limited Hidden Water or Seepage/Leakage Included Excluded Equipment Breakdown Coverage Included Excluded Service Line Enhancement Coverage Included Excluded Alarm System (fire and police) or Cameras Yes No Interior Sprinkler System Yes No Automatic Shut Off; water and/or gas Yes No Short-Term Rental (VRBO, AirBnb) Yes No Dog(s) Yes No Breed(s) Additional Animal(s) Yes No Please specify Does the property have a wood stove? Yes No Trampoline No Trampoline - With Net Trampoline - No Net Pool Pool - No Slide Pool - Has Slide No pool Short- Term Rental (VRBO, AirBnb) Yes No MotorcycleHow Many Motorcycle Drivers?(Required)12345How Many Motorcycles?(Required)12345Bodily Injury Liability50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000UM/UIM50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000PIP or Medical PIP Medical Decline PIP Limit$10,000$35,000Please specify the Medical Limit Primary Driver(Required) First Last Motorcycle Driver #2 First Last Motorcycle Driver #3 First Last Motorcycle Driver #4 First Last Motorcycle Driver #5 First Last Motorcycle #1Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageLicensed For Street Use Yes No Towing/Roadside Included Excluded Ride Share or Delivery (Uber, Lyft, etc.) Yes No Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Accident Forgiveness Included Excluded New Vehicle Replacement Included Excluded Modifications Yes No List Modifications Loan/Lease "Gap" Coverage Included Excluded Leinholder/Lease Yes No Motorcycle #2Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageLicensed For Street Use Yes No Towing/Roadside Included Excluded Ride Share or Delivery (Uber, Lyft, etc.) Yes No Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Accident Forgiveness Included Excluded New Vehicle Replacement Included Excluded Modifications Yes No List Modifications Loan/Lease Included Excluded Leinholder/Lease Yes No Motorcycle #3Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageLicensed For Street Use Yes No Towing/Roadside Included Excluded Ride Share or Delivery (Uber, Lyft, etc.) Yes No Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Accident Forgiveness Included Excluded New Vehicle Replacement Included Excluded Modifications Yes No List Modifications Loan/Lease Included Excluded Leinholder/Lease Yes No Motorcycle #4Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageLicensed For Street Use Yes No Towing/Roadside Included Excluded Ride Share or Delivery (Uber, Lyft, etc.) Yes No Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Accident Forgiveness Included Excluded New Vehicle Replacement Included Excluded Modifications Yes No List Modifications Loan/Lease Included Excluded Leinholder/Lease Yes No Motorcycle #5Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageLicensed For Street Use Yes No Towing/Roadside Included Excluded Ride Share or Delivery (Uber, Lyft, etc.) Yes No Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Accident Forgiveness Included Excluded New Vehicle Replacement Included Excluded Modifications Yes No List Modifications Loan/Lease Included Excluded Leinholder/Lease Yes No Motorhome/RVTotal Motorhome/RV Drivers(Required)12345Total Motorhomes/RV(Required)12345Bodily Injury Liability50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000Vacation Liability Yes No Coverage Limit Contents Coverage Yes No Coverage Limit Full Timer Coverage Yes No Driver InformationPrimary Motorhome/RV Driver First Last Motorhome/RV Driver #2 First Last Motorhome/RV Driver #3 First Last Motorhome/RV Driver #4 First Last Motorhome/RV Driver #5 First Last Motorhome/RV #1Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded NumberCommercial Use Included Excluded Glass with $0 deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Loan/Lease (GAP Coverage) Included Excluded Motorhome/RV Modifications Yes No List Modifications New Vehicle Replacement Included Excluded Leinholder/Lease Yes No Motorhome/RV #2Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded NumberCommercial Use Included Excluded Glass with $0 deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Loan/Lease (GAP Coverage) Included Excluded Motorhome/RV Modifications Yes No List Modifications New Vehicle Replacement Included Excluded Leinholder/Lease Yes No Motorhome/RV #3Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded NumberCommercial Use Included Excluded Glass with $0 deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Loan/Lease (GAP Coverage) Included Excluded Motorhome/RV Modifications Yes No List Modifications New Vehicle Replacement Included Excluded Leinholder/Lease Yes No Motorhome/RV #4Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded NumberCommercial Use Included Excluded Glass with $0 deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Loan/Lease (GAP Coverage) Included Excluded Motorhome/RV Modifications Yes No List Modifications New Vehicle Replacement Included Excluded Leinholder/Lease Yes No Motorhome/RV #5Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded NumberCommercial Use Included Excluded Glass with $0 deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Loan/Lease (GAP Coverage) Included Excluded Motorhome/RV Modifications Yes No List Modifications New Vehicle Replacement Included Excluded Leinholder/Lease Yes No Boat/Jet SkiNumber of Boat/Jet Ski Operators12345Number of Boats/Jet Skis12345Bodily Injury Liability50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000Primary Operator Operator #2 Operator #3 Operator #4 Operator #5 Total Drivers(Required)12345Total Vehicles(Required)12345Driver InformationPrimary Driver(Required) First Last Driver #2 First Last Driver #3 First Last Driver #4 First Last Driver #5 First Last Boat/Jet Ski #1Insured Item Boat Jet Ski Uninsured Boater Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsHull Damage/Deductible Included Excluded Hull Damage/DeductibleHull LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #1Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Boat/Jet Ski #2Insured Item Boat Jet Ski Uninsured Boater Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsHull Damage/Deductible Included Excluded Hull Damage/DeductibleHull LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #2Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Boat/Jet Ski #3Insured Item Boat Jet Ski Uninsured Boater Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsHull Damage/Deductible Included Excluded Hull Damage/DeductibleHull LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #3Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Boat/Jet Ski #4Insured Item Boat Jet Ski Uninsured Boater Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsHull Damage/Deductible Included Excluded Hull Damage/DeductibleHull LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #4Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No Boat/Jet Ski #5Insured Item Boat Jet Ski Uninsured Boater Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsHull Damage/Deductible Included Excluded Hull Damage/DeductibleHull LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #5Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No ATV/SnowmobileNumber of ATV/Snowmobile Operators12345Number of ATV/Snowmobiles12345Bodily Injury Liability50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000Primary Operator Operator #2 Operator #3 Operator #4 Operator #5 Total Drivers(Required)12345Total Vehicles(Required)12345Driver InformationPrimary Driver(Required) First Last Driver #2 First Last Driver #3 First Last Driver #4 First Last Driver #5 First Last ATV/Snowmobile #1Insured Item ATV Snowmobile UM/UIIM Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsPhysical Damage/Deductible Included Excluded Physical Damage/DeductibleVehicle LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #1Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No ATV/Snowmobile #2Insured Item ATV Snowmobile UM/UIIM Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsPhysical Damage/Deductible Included Excluded Physical Damage/DeductibleVehicle LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #2Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No ATV/Snowmobile #3Insured Item ATV Snowmobile UM/UIIM Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsPhysical Damage/Deductible Included Excluded Physical Damage/DeductibleVehicle LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #3Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitDoes the property have a wood stove? Yes No Ride Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No ATV/Snowmobile #4Insured Item ATV Snowmobile UM/UIIM Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsPhysical Damage/Deductible Included Excluded Physical Damage/DeductibleVehicle LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #4Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No ATV/Snowmobile #5Insured Item ATV Snowmobile UM/UIIM Included Excluded Liability Included Excluded LiabilityMedical Payments Included Excluded Medical PaymentsPhysical Damage/Deductible Included Excluded Physical Damage/DeductibleVehicle LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded Vehicle #5Year Make Model Collision Deductible$100$250$500$1000Decline - No CoverageComprehensive Deductible$100$250$500$1000Decline - No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental LimitRide Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded OEM Parts Included Excluded Vehicle in storage Yes No Telematics Included Excluded Accident Forgiveness Included Excluded Modifications Included Excluded List Modifications New Vehicle Replacement Included Excluded Loan/Lease (GAP Coverage) Included Excluded Leinholder/Lease Yes No UmbrellaUmbrella Limit$1M$2M$3M$4M$5M$10M$15M$20MUninsured Motorist$1M$2M$3M$4M$5M$10M$15M$20MPolicy(ies) covered by Umbrella policy Auto Home Condo Renters Rental Property Second Home Boat/Watercraft Motorcycle ATV/RV Mobile Home Classic Auto Other What other type of insurance Life InsuranceInsured Person Type of Life Insurance Death Benefit Life InsuranceLife Insurance(Required) Life insurance options have been discussed and the insured is not interested at this time Customer SignatureName First Last
