FirstMark – Coverage Checklist Coverage Checklist – FirstMark Step 1 of 16 6% Writing Agent(Required)Amanda SheaAndrew Cowan'Bradley StampfliDaniel FortuneDavid TaylorErin CaseyGail WelfringerGracia OlivasJohn ApplegateJohn KorpiKenneth MeyerKirby WarrenLaMia HayekLevi ChambersMatt SmithMichael DonnellyNolan WelfringerProduction TeamRichard HarrisonRiley McAuliffeRobert BalderasRosemary RamirezSaopon ChaScott WoosterSusie TaylorClient Name(Required) 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 Marital StatusMarriedSingleDivorcedDomestic PartnerWidowedAdditional Insured(Required) First Last AutoEffective Date(Required) MM slash DD slash YYYY 6/12 Month612Bodily 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/UIM50/100100/300250/500250/500CSL 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+Additional Notes/InfoDriver 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$200$250$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$250$300$500$1000$1500$2000$2500Decline – No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental Limit Ride Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded $50 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$200$250$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$250$300$500$1000$1500$2000$2500Decline – No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental Limit Ride Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded $50 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$200$250$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$250$300$500$1000$1500$2000$2500Decline – No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental Limit Ride Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded $50 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$200$250$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$250$300$500$1000$1500$2000$2500Decline – No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental Limit Ride Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded $50 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$200$250$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$250$300$500$1000$1500$2000$2500Decline – No CoverageTowing/Roadside Included Excluded Rental Car Included Excluded Rental Limit Ride Share or Delivery (Uber, Lyft, etc.) Included Excluded Commercial Use Included Excluded $0 Glass Deductible Included Excluded $50 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 AutoEffective Date(Required) MM slash DD slash YYYY YearMake 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – No Coverage$0 Glass Deductible Included Excluded $50 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 Additional Notes/Info Primary HomeEffective Date(Required) MM slash DD slash YYYY Deductible$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 HomeEffective Date(Required) MM slash DD slash YYYY Deductible$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 Additional Notes/Info Condominium InfoEffective Date(Required) MM slash DD slash YYYY DeductibleMortgage/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 LimitAdditional Notes/Info RentersEffective Date(Required) MM slash DD slash YYYY Policy 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 Protection/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 LimitAdditional Notes/Info LandlordEffective Date(Required) MM slash DD slash YYYY Property 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 Additional Notes/Info MotorcycleEffective Date(Required) MM slash DD slash YYYY How 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 Additional Notes/InfoMotorcycle #1Year Make Model Collision Deductible$100$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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/RVEffective Date(Required) MM slash DD slash YYYY Total 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 Additional Notes/InfoDriver 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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 SkiEffective Date(Required) MM slash DD slash YYYY Number of Boats/Jet Skis12345Bodily Injury Liability50,000/100,000/50,000100,000/300,000/100,000250,000/500,000/250,000CSL 300,000CSL 500,000Total Drivers(Required)12345Additional Notes/InfoDriver 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/Deductible Limit$250OtherOther Hull LimitOutboard Motor LimitTrailer Damage/Deductible Included Excluded Trailer Damage/DeductiblePersonal Effects Included Excluded Additional Equipment Included Excluded Additional EquipmentEmergency Services Included Excluded 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 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 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 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 ATV/SnowmobileEffective Date(Required) MM slash DD slash YYYY Number of ATV/Snowmobile Operators(Required)12345Number of ATV/Snowmobiles(Required)12345Bodily 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)12345Additional Notes/InfoDriver 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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 Comprehensive Deductible$100$200$300$500$1000$1500Decline – No CoverageCollision Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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 Comprehensive Deductible$100$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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 Comprehensive Deductible$100$200$300$500$1000$1500Decline – No CoverageComprehensive Deductible$100$200$300$500$1000$1500$2000$2500Decline – 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 UmbrellaEffective Date(Required) MM slash DD slash YYYY Umbrella Limit$1M$2M$3M$4M$5M$10M$15M$20MNOUninsured MotoristNone$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 Additional Notes/Info Life InsuranceEffective Date(Required) MM slash DD slash YYYY Insured Person Type of Life Insurance Death Benefit Additional Notes/Info Life InsuranceLife Insurance(Required) Life insurance options have been discussed and the insured is not interested at this timeAdditional Notes/Info As per our company policy, all clients are required to sign the insurance coverage review form to confirm that they have received and understood the information provided.Customer SignatureName First Last
