Please fill out information on form as completely as possible for the state of Kentucky.  Simms & Montgomery is authorized only to write insurance in the state Kentucky. If you have any questions about this form or making a claim, please contact us. In order to provide you with the most accurate quote available, please include your Social Security Number.  However, if you would rather not enter that information, we can still provide you with a quote.
Personal Information
Name (first,  middle, last) :
Address line 1:
Address line 2:
Address (city, state, zip code) :
E-mail:			Social Security #:
Home Phone:		Work Phone:
Fax:		Best time to call:
Vehicle Info
Year:	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:
Model:		Vehicle I.D. #:
Annual Mileage:
Air Bag or electric seatbelt?	yes no	Anti-theft device?		yes no
Driver Information
Years of driving experience:		Driver training?		yes no
Please list all tickets and/or accidents in the last six years, or SDIP step if known:
Please list dates of birth and drivers license #'s for all operators (primary driver required:	Date of Birth (list primary first - required):		Drivers License # (list primary first - required):
Secondary
Additional Driver3
Additional Driver4
Coverage Options:
Part 1 - Bodily Injury to others:	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $60,000 SL $100,000 SL $300,000 SL $500,000 SL * SL - Single Limit
Part 2 - Property damage:	$10,000 $25,000 $50,000 $100,000 $200,000
Part 3 - Personal Injury Protection:	$10,000 $20,000 $30,000 $40,000 $50,000
Part 4 - Uninsured Motorist:	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Part 5 - Underinsured Motorist:	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Part 6 - Optional Bodily Injury:	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Part 7 - Comprehensive (deductible):	No deduct. $50 $100 $250 $500 $1,000
Part 8 - Collision (deductible):	No deduct. $50 $100 $250 $500 $1,000
Part 8 - Limited Collision:	yes no
Part 11 - Towing and Labor:	$50 $75 $100
	Please note that submitting an insurance quotation request to Simms & Montgomery does not constitute a binding confirmation of new or altered insurance coverage. Written confirmation must be obtained from Simms & Montgomery to confirm binding or altering coverage.