ATV/Four Wheeler QuoteTo complete this quote form, you should know the following: Name, date of birth, martial status, gender, driver’s license number, violations, and accidents for each person on your policyYear, make, model, and VIN number of ATVATV specificationsAmount of insurance desired (explanations provided within the form)This form accommodates two drivers for the ATV. If you have more than two drivers, feel welcome to contact us. Driver 1 Information First Name * Middle Initial * Last Name * Email * Phone Number * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Male Female Date of Birth * MM DD YYYY Marital Status * Married Single Divorced Widowed Driver's License Number * Any automobile accidents in the last 3 years? * Yes, at fault Yes, not at fault No If yes, what was the date? MM DD YYYY Any minor violations in the last 3 years? * Examples include a speeding ticket, seat belt violation, issues with registration/titling/licensing Yes No If yes, what was the date? MM DD YYYY Any major violations in the last 5 years? * Examples include DUI, DWI, reckless driving Yes No If yes, what was the date? MM DD YYYY Driver 2 Information (if applicable) If there is only one driver, please skip this and move onto the Vehicle Information section. First Name Middle Initial Last Name Gender N/A Male Female Date of Birth MM DD YYYY Marital Status N/A Married Single Divorced Widowed Driver's License Number Any automobile accidents in the last 3 years? Yes, at fault Yes, not at fault No If yes, what was the date? MM DD YYYY Any minor violations in the last 3 years? Examples include a speeding ticket, seat belt violation, issues with registration/titling/licensing Yes No If yes, what was the date? MM DD YYYY Any major violations in the last 5 years? Examples include DUI, DWI, reckless driving Yes No If yes, what was the date? MM DD YYYY Vehicle Information Date Purchased * MM DD YYYY Year Built * Make and Model * Vehicle VIN Number * Does the vehicle have anti-lock brakes? * Yes No Is the vehicle stored in a locked garage? * Yes No Is the garage location different than the address listed at the beginning of the survey? * Yes No Vehicle is not stored in a garage If yes, what is the garage address? Address 1 Address 2 City State/Province Zip/Postal Code Country Have you completed a state approved safety course? * Yes No Is SR-22 filing required for your vehicle? * Yes No Trailer Information Please skip this set of questions and move onto the next section if you do not have a trailer. Year Built Trailer Make and Model Trailer Length Trailer VIN Number Insurance Information Do you have any policies with Nationwide? * Select all that apply. No Auto Commercial Home Life and/or Annuity What is your primary residence? * Homeowner Condo Mobile home Rent home Rent apartment Rent mobile home Is the vehicle currently insured? * Yes No Would you like to pay the insurance in full? * By paying the insurance for the year in full, you may be eligible for a discount. Yes No Who is your previous insurance provider for the vehicle? Input "N/A" if the vehicle has not previously been insured. Coverage Desired Please answer the following questions to the best of your ability. If you're unsure of anything, feel welcome to contact us. Desired Coverage Type * Actual cash value is the replacement cost of the vehicle minus depreciation. Agreed value is a pre-determined value settled on by the insured and the insurance company. Actual cash value Agreed value If you selected 'agreed upon' as the coverage type, what value would you like quoted for? Input "N/A" if not applicable. Bodily Injury Coverage * This coverage helps pay for another person's injuries or damage when you are at-fault in an accident. The first number is the maximum amount that will be paid out to any one individual. The second number is the maximum amount that will be paid out to a group of people (if applicable). The third number is the maximum amount that will be paid out for property damage. The amount of coverage you carry should be enough to protect your assets in the event of an accident. These numbers are listed in thousands of dollars. 25/50/10 50/50/50 50/100/25 100/300/50 100/100/100 100/300/100 250/500/100 300/300/300 300/300/100 500/500/100 500/500/500 Un-insured/Under-insured Motorists Bodily Injury Coverage * This coverage protects you and the insured members of your household/your passengers for injuries, damage, or death caused by an at-fault driver who either does not have insurance or does not have enough insurance. The first number is the maximum amount that will be paid out to any one individual. The second number is the maximum amount that will be paid out to a group of people (if applicable). The amount of coverage you carry should be enough to protect your assets in the event of an accident. These numbers are listed in thousands of dollars. 25/25 50/50 100/100 300/300 500/500 Medical Coverage * Medical coverage helps pay for your or your passenger's medical expenses if injured in an accident, regardless of who is at fault. $1,000 $2,500 $5,000 $10,000 Comprehensive Deductible * This is the amount you will pay after filing a claim before the insurance coverage kicks in. Comprehensive coverage includes things outside of an accident (tree falling on vehicle, vandalism, stolen vehicle, etc.) $100 $250 $500 $1,000 I do NOT want comprehensive coverage Collision Deductible * This is the amount you will pay after filing a claim before the insurance coverage kicks in. Collision coverage protects YOUR vehicle for collisions (rear-ending someone, drive into a tree, hit a fence, etc.) $100 $250 $500 $1,000 I do NOT want collision coverage Un-Insured Motorist Property Damage Coverage * This coverage pays for damage caused to your vehicle if it is hit by an un-insured driver. This coverage is only necessary if you do not have Collision Coverage. This may cover up to $25,000 with a $250 deductible. Yes No OEM Endorsement * OEM insurance is additional coverage added onto your insurance policy. It ensures that original manufacturer parts are used to repair your vehicle, rather than aftermarket parts. Yes No Roadside Assistance * Yes No Preferred insurance premium payment frequency * Monthly Quarterly Semi-Annually Annually Additional comments or questions Thank you for requesting a quote from Michael Logue Insurance. We will be in touch with the quote within 1 business day.
