Our Services - Vehicle

Your vehicle is more than convenient and dependable transportation, it is a substantial investment, second only to your home, and repairs are costly too. Adequate coverage is vital; your vehicle is a valuable asset that needs protection.

That is where we can help. We will explain and recommend coverages and show you discounts for multiple vehicles, safe drivers and other ways to save money. Ask us about commercial vehicles, too. For detail, complete and send the following "Request for a Quote", call us at (410) 992-5700 or send Email to   info@patuxentinsurance.com.

Name:

Address:

City:

State:

Zip Code:

Home Phone:

Business Phone:

Email Address:

Occupation:

Employer:

Present Insurance Co.:

Date Policy Expires:

Present Liability Coverage (bodily injury/property damage)$:

Collision Deductible$:

Comprehensive Deductible$:

Car #1

Year:

Make:

Model (complete description):

Miles one-way to work:

Used in business:

No        Yes

Principle Driver Age:

Principle Driver Sex:

Female   Male

Principle Driver "B" Student:

No   Yes

Principle Driver Last 3 years # Citations:

Principle Driver Last 3 years Accident Date:

Occasional Driver Age:

Occasional Driver Sex:

Female   Male

Occasional Driver "B" Student:

No   Yes

Occasional Driver Last 3 years # Citations:

Occasional Driver Last 3 years Accident Date:

Car #2

Year:

Make:

Model (complete description):

Miles one-way to work:

Used in business:

No        Yes

Principle Driver Age:

Principle Driver Sex:

Female   Male

Principle Driver "B" Student:

No   Yes

Principle Driver Last 3 years # Citations:

Principle Driver Last 3 years Accident Date:

Occasional Driver Age:

Occasional Driver Sex:

Female   Male

Occasional Driver "B" Student:

No   Yes

Occasional Driver Last 3 years # Citations:

Occasional Driver Last 3 years Accident Date:

Car #3

Year:

Make:

Model (complete description):

Miles one-way to work:

Used in business:

No        Yes

Principle Driver Age:

Principle Driver Sex:

Female   Male

Principle Driver "B" Student:

No   Yes

Principle Driver Last 3 years # Citations:

Principle Driver Last 3 years Accident Date:

Occasional Driver Age:

Occasional Driver Sex:

Female   Male

Occasional Driver "B" Student:

No   Yes

Occasional Driver Last 3 years # Citations:

Occasional Driver Last 3 years Accident Date:

Comments:

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