Please fill out as much information as possible and fax to 870-338-2768. If you have any questions about this form or filing a claim, please e-mail us or call us at 870-338-3559 or toll free at 888-883-4462. Submitting an insurance quotation request to HNB Insurance Agency does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from HNB Insurance to confirm binding or altering coverage.
Name:
Address (city, state, zip code):
E-mail:
Telephone:
Fax:
Best time to call:
Sex:	Driver #1 Male Female Driver #2 Male Female
Social Security Number:	Driver #1 Driver #2
Date of birth	Driver #1 Driver #2
Occupation:	Driver#1 Employed Unemployed Retired Student Driver#2 Employed Unemployed Retired Student
In the last 5 years, have you had an accident or loss?	Driver #1 Yes No Driver #2 Yes No
In the last 5 years, have you had any violations?	Driver #1 Yes No Driver #2 Yes No
Do you own your own home?	Driver #1 Yes No Driver #2 Yes No
Years at current residence:	Driver #1 Driver #2
Year:	Vehicle #1 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 Vehicle #2 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960
Make:	Vehicle #1 Vehicle #2
Model:	Vehicle #1 Vehicle #2
Vehicle I.D. #:  (Serial Number - 17 digits)	Vehicle #1 Vehicle #2
Annual Mileage:	Vehicle #1 Vehicle #2
Air bag or electric seatbelt?	Vehicle #1 yes no Vehicle #2 yes no
Anti-theft device?	Vehicle #1 yes no Vehicle #2 yes no
Coverage Options:
Bodily Injury to others:	$25,000 per person / $50,000 per accident
Property damage:	$25,000 $50,000 $100,000 $250,000
Uninsured Motorist:	Vehicle #1 $20,000/$40,000 $20,000/$50,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000 CSL Vehicle #2 $20,000/$40,000 $20,000/$50,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000 CSL
Uninsured Motorist Property Damage:	Vehicle #1 $20,000/$40,000 $20,000/$50,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000 CSL Vehicle #2 $20,000/$40,000 $20,000/$50,000 $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000 CSL
Underinsured Motorist:	Vehicle #1 $20,000/$40,000 $20,000/$50,000 $25,000/$50,000 $35,000/$80,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000 $500,000/$1,000,000 Vehicle #2 $20,000/$40,000 $20,000/$50,000 $25,000/$50,000 $35,000/$80,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$500,000 $500,000/$1,000,000
Personal Injury Protection:	$5,000
Collision (deductible):	Vehicle #1 no coverage $250 $500 $1,000 Vehicle #2 no coverage $250 $500 $1,000
Comprehensive (deductible):	Vehicle #1 no coverage $100 $250 $500 $1,000 Vehicle #2 no coverage $100 $250 $500 $1,000
Rental car:	Vehicle #1 no coverage $15/day $450 max. $30 day $900 max. Vehicle #2 no coverage $15/day $450 max. $30 day $900 max.
Towing and Labor:	Vehicle #1 no coverage $50 per disablement $75 per disablement Vehicle #2 no coverage $50 per disablement $75 per disablement