Benefits Plus Auto

Which of our groups are you with?
---William LumberAstor ServicesRhinebeck Area ChamberNorthern Dutchess ParamedicsHealth-Quest
Name

Address

Telephone

Email

Driver 1
Name Date of Birth Drivers License Number Social Security Number
Do you have any of the following?
---AccidentsTicketsClaimsAll of the Above
If Yes, please give a brief explanation

What is your highest level of Education?
---High SchoolAssociates DegreeBachelors DegreeMasters DegreePhD
Driver 2
Name

Date of Birth

Drivers License Number

Social Security Number

Do you have any of the following?
---AccidentsTicketsClaimsAll of the Above
If Yes, please give a brief explanation

What is your highest level of Education?
---High SchoolAssociates DegreeBachelors DegreeMasters DegreePhD
Are their any other drivers or regular operators of your vehicles?
yesno
If Yes, Please provide some details

Vehicle Information Section
Year Make Model
Year Make Model
Year Make Model
Coverage Section
What are your current liability limits? ---25,000/50,00050,000/100,000100,000/300,000250,000/500,00050,000100,000300,000500,0001,000,000
What are your current Uninsured/Underinsured limits? ---25,000/50,00050,000/100,000100,000/300,000250,000/500,00050,000100,000300,000500,0001,000,000
What is your Aggregate Personal Injury Protection? ---50,000100,000125,000150,000175,000
Is there Comprehensive and Collision Coverage on your vehicles? ---None of themSome of themAll of them
Comprehensive and Collision Deductibles ---0501002505001,000Various
How did you learn about the program? ---NewsletterE-mailPayroll StufferOnsite visitBenefits fair
Please use this link to upload a copy of your current Declarations page, by doing this you will speed up the process and increase accuracy.
File types limited to gif, tif, jpg and pdf