September 9, 2010 i
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INFORMATION DISCLOSURE
In order to provide you with an accurate quote from one of our insurance carriers, we may need to collect information from consumer reporting agencies, such as driving record, claims, and credit history reports.
Please read Southern Indiana Insurance's Privacy Policy.

I have read the information disclosure, reviewed the privacy policy and want to continue.

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GENERAL CONTACT INFORMATION
First Name Primary Phone Number
Last Name Secondary Phone Number
Address Best time to call
City Email Address
State Indiana Kentucky
Zip Code

CURRENT/PRIOR COVERAGE INFORMATION
Do you currently have auto insurance? Yes No
(If you answered NO, click here to go to the next question.)
Who is your current auto insurance provider?
How long have you had auto insurance? Years Months
Date your current auto insurance coverage expires?
Vehicle Information
Vehicle
VIN Number
(if available)
Year
Make
Model
1
2
3
4
5
Please call 812-941-8400 for quotes with more than 5 vehicles.
Liability and Coverage Limits
Please select the coverage limits you would like to be quoted. These coverage amounts are used in quoting insurance rates.
These coverages can be adjusted when discussing final coverage.
Veh.
Bodily Injury Liability
 Property
Damage
Un/Under Insured Motorists
Medical Pay
Comprehensive Deductible
Collision Deductible
Towing
(day)
Rental
(day/max)
1
Liability limit will be the same for all vehicles.
Limit will be the same for all vehicles.
Limit will be the same for all vehicles.
Medical pay will be the same for all vehicles.
2
3
4
5
Please call 812-941-8400 for quotes with more than 5 vehicles.
Driver Information
# Driver(s)
Name		 Social Security Number Sex: Date of Birth # of Tickets in last 3 years # Accidents in last 3 years
1 Male
Female
2
Male
Female
3 Male
Female
4 Male
Female
5 Male
Female

Please explain/describe any accidents or tickets reported above.

Please call 812-941-8400 for quotes with more than 5 drivers.

Once all of the above questions have been answered correctly click submit.

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