Elite Insurance Solutions
2719 Letap Court #102,
Land O' Lakes, FL, 34638
jreeves@geteliteinsurance.com
www.GetEliteInsurance.com
(813) 475-5099
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Full Name
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First Name
Last Name
Address
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Do you own, rent, or live with parents?
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Prior Carrier
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Years with Carrier
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Driver 1
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Name
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Date of Birth
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Drivers License Number
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Marital Status
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Occupation
Driver 2
Name
Date of Birth
Drivers License Number
Marital Status
Occupation
Relation to insured
Spouse
Child
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Driver 3
Name
Date of Birth
Drivers License Number
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Child
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Driver 4
Name
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Vehicle 1
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Year, Make, Model
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VIN
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Own/Lease/Finance
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Own
Lease
Finance
Vehicle Usage
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Business
Pleasure
Work
School
Miles one way
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Used for Ridesharing (Uber/Lyft)
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Yes
No
Used for Delivery
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Yes
No
Vehicle 2
Year, Make, Model
VIN
Own/Lease/Finance
Own
Lease
Finance
Vehicle Usage
Business
Pleasure
Work
School
Miles one way
Used for Ridesharing (Uber/Lyft)
Yes
No
Used for Delivery
Yes
No
Vehicle 3
Year, Make, Model
VIN
Own/Lease/Finance
Own
Lease
Finance
Vehicle Usage
Business
Pleasure
Work
School
Miles one way
Used for Ridesharing (Uber/Lyft)
Yes
No
Used for Delivery
Yes
No
Vehicle 4
Year, Make, Model
VIN
Own/Lease/Finance
Own
Lease
Finance
Vehicle Usage
Business
Pleasure
Work
School
Miles one way
Used for Ridesharing (Uber/Lyft)
Yes
No
Used for Delivery
Yes
No
Bodily Injury Liablity
*
No BI
10/20
25/50
50/100
100/300
250/500
Property Damage Liability
*
$10K
$20K
$25K
$50K
$100K
$250K
$500K
Comp deductible
*
$0
$100
$250
$500
$750
$1000
$1500
$2000
No coverage needed
Collision deductible
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$0
$100
$250
$500
$750
$1000
$1500
$2000
No coverage needed
Rental Coverage
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$30/$900
$40/$1200
$50/$1500
$100/$3000
None
Towing Coverage
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Yes
No
Medical Payments Coverage
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$1,000
$2,000
$3,000
$4,000
$5,000
No coverage needed
Any accidents or tickets? Please list driver, date of accident or violation, and description.
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