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	Fields highlighted in bold are required    Your Information     First Name:               Last Name:        Address:    City:            State:    AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AA AE AP AS FM GU MH MP PR PW VI            ZIP:  Email:      Phone:         Fax:   Rent or Own Home?               Please Select... Rent Own Other Current Insurance:        YesNo          Provider:  Coverage Start Date:                  End Date:     Driver Information       Driver #1     Full Name:         Date of Birth:    Tickets/Accidents/Claims in last 3 years:    Driver #2     Full Name:         Date of Birth:  Tickets/Accidents/Claims in last 3 years:    Driver #3     Full Name:        Date of Birth:  Tickets/Accidents/Claims in last 3 years:    Driver #4     Full Name:        Date of Birth:  Tickets/Accidents/Claims in last 3 years:    Requested Coverage and Vehicle Information      Vehicle #1   Year:       Make:        Model:        Primary Driver:                                Primary Use:    Please Select... Work School Other Miles to Work/School:                                                   Annual Mileage:    Is there a lien on this vehicle?  Yes       No Liability:            Yes  No           Coverage Desired:     Please Select... 25/50 50/100 100/300 250/500 PIP:                  Yes  No           Coverage Desired:     Please Select... 15,000 35,000 Comp Ded:       Yes  No           Coverage Desired:     Please Select... 0 50 100 200 250 500 1000 Coll Ded:          Yes  No           Coverage Desired:     Please Select... 0 50 100 200 250 500 1000 UMPD:            Yes  No           Coverage Desired:     Please Select... 10 25 50 100 Towing Coverage:            Yes  No Rental Coverage:              Yes  No    Vehicle #2   Year:      Make:       Model:  Primary Driver:                                Primary Use:  Please Select... Work School Other Miles to Work/School:                                                    Annual Mileage:  Is there a lien on this vehicle?  Yes No Liability:            Yes  No           Coverage Desired:     Please Select... 25/50 50/100 100/300 250/500 PIP:                  Yes  No           Coverage Desired:     Please Select... 15,000 35,000 Comp Ded:       Yes  No           Coverage Desired:     Please Select... 0 50 100 200 250 500 1000 Coll Ded:          Yes  No           Coverage Desired:     Please Select... 0 50 100 200 250 500 1000 UMPD:            Yes  No           Coverage Desired:     Please Select... 10 25 50 100 Towing Coverage:            Yes  No Rental Coverage:              Yes  No    Vehicle #3   Year:      Make:      Model:  Primary Driver:                               Primary Use:  Please Select... Work School Other Miles to Work/School:                                                   Annual Mileage:  Is there a lien on this vehicle?  Yes No Liability:            Yes No           Coverage Desired:     Please Select... 25/50 50/100 100/300 250/500 PIP:                  Yes No           Coverage Desired:     Please Select... 15,000 35,000 Comp Ded:       Yes No           Coverage Desired:     Please Select... 0 50 100 200 250 500 1000 Coll Ded:          Yes No           Coverage Desired:     Please Select... 0 50 100 200 250 500 1000 UMPD:            Yes No           Coverage Desired:     Please Select... 10 25 50 100 Towing Coverage:            Yes No Rental Coverage:              Yes No    Vehicle #4   Year:      Make:      Model:  Primary Driver:                               Primary Use:  Please Select... Work School Other Miles to Work/School:                                                   Annual Mileage:  Is there a lien on this vehicle?  Yes No Liability:            Yes  No           Coverage Desired:     Please Select... 25/50 50/100 100/300 250/500 PIP:                  Yes  No           Coverage Desired:     Please Select... 15,000 35,000 Comp Ded:       Yes  No           Coverage Desired:     Please Select... 0 50 100 200 250 500 1000 Coll Ded:          Yes  No           Coverage Desired:     Please Select... 0 50 100 200 250 500 1000 UMPD:            Yes  No           Coverage Desired:     Please Select... 10 25 50 100 Towing Coverage:            Yes  No Rental Coverage:              Yes  No     Please Contact Me Via    Telephone           Email          Fax           Mail

Gelfand Insurance Group, Inc Hours: Monday - Friday, 9am - 5pm info@gelfandinsurance.com West Linn Office 1975 SW 8th Avenue West Linn, OR. 97068 (503) 650-3727 Fax:  (503) 650-3828 westlinn@gelfandinsurance.com Scappoose Office 33480 SW Chinook Plaza Scappoose, OR 97054 (503) 543-0994 Fax:   (503) 543-0975 scappoose@gelfandinsurance.com Vancouver Office 9013 NE Highway 99 Suite A Vancouver, WA 98665 (360) 882-0619 Fax:  (360) 883-2204 vancouver@gelfandinsurance.com (C) 2008 BriteWeb Designs, an affiliate of BriteWare Technologies, Inc.