F. A. Peabody Company
Automobile Insurance Quote Form

F. A. Peabody Company is licensed to do business in the State of Maine ONLY with offices in
Houlton, Caribou, Hampden, Lincoln, Mars Hill, Presque Isle, and Sherman Mills.   Our Caribou office also does business as Equinox of Aroostook offering insurance products to Credit Union Members in Aroostook County.    All information provided will be held CONFIDENTIAL and used only for responding to your request.
Completion of all fields will provide you with the most accurate quote.
All fields in RED require input
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General Information
 
First Name:
Last Name:
Mailing Address:
Street Address:
City:   State: ME    ZIP:
County: Email:
Home Phone:
Work Phone:
Fax:
Best time to call: AM PM
Call home or work?: Home   Work
Prefer contact by: Phone Mail E-Mail
Are you a smoker?: Yes   No
Marital Status: Married Single
Drive to work?: Yes   No                  Miles one way

Liability Limits

Bodily Injury: Property Damage:    (SPLIT)

-OR-

Bodily Injury/Property Damage: (SINGLE)

Medical Payments:   Uninsured Motorists:
Towing:     Rental:    Other: 
Current Auto Insurance Coverage:
Company Name:
Policy Exp. Date:
Are you being cancelled: Yes   No
If yes, why?:
Premium: $
Term: 6 Months   1 Year   Other  
Vehicle Information:
(include all cars you or your family members own or lease)
Car #1 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
Name of Title Holder
 Annual Mileage
 Drive to school, work?
Yes   No
# of miles (one way): 		Car equipped with
ABS
Passenger Restraints
Anti-theft device
Air Bags

Comprehensive Deductible:                                                      Collision Deductible:

If Pickup, is there a plow?:Yes   No         Value:

If Pickup, is there a cap?:Yes   No          Value:

Existing Damage:
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
Car #2 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
Name of Title Holder
 Annual Mileage
 Drive to school, work?
Yes   No
# of miles (one way): 		Car equipped with
ABS
Passenger Restraints
Anti-theft device
Air Bags

Comprehensive Deductible:                                                      Collision Deductible:

If Pickup, is there a plow?:Yes   No         Value:

If Pickup, is there a cap?:Yes   No          Value:

Existing Damage:
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
Car #3 Year Make Model Sub Model Body Type Vehicle ID# (VIN)
Name of Title Holder
 Annual Mileage
 Drive to school, work?
Yes   No
# of miles (one way): 		Car equipped with
ABS
Passenger Restraints
Anti-theft device
Air Bags

Comprehensive Deductible:                                                      Collision Deductible:

If Pickup, is there a plow?:Yes   No         Value:

If Pickup, is there a cap?:Yes   No          Value:

Existing Damage:
If vehicle is kept at an address other than that listed above, please indicate:
Location City:   State:   Zip:
Driver Information:
(including all licensed drivers in your household)
Driver's Name Occupation Relation
to you		 Date of birth
(Mo/Day/Yr)		 Male/
Female

M / F

 Married/
Single

M / S

 Completed Youthful High School or College # of Yrs.
Licensed		 % of Vehicle Use
Good Student Drivers Education #1 #2 #3
Self  M
F		 M
S		  Y
N		 Y
N		 High School
College		      
M
F		 M
S		 Y
N		 Y
N		 High School
College
M
F		 M
S		 Y
N		 Y
N		 High School
College
M
F		 M
S		 Y
N		 Y
N		 High School
College
Must add to:   100% 100% 100%
Driver History
If you answer "yes" to any of the following questions below,
please explain in the space provided:

Has any driver listed:

1. Been convicted of any moving traffic violation in the past 3 years?
      Yes   No
    If yes, please answer the following:

Driver Date Type of Conviction Time Speed
Over Limit
MPH
MPH
MPH
MPH

2. Had his/her license suspended or revoked?
    Answer only if "yes":

Driver Suspended Revoked
Yes Yes
Yes Yes
Yes Yes
Yes Yes

3. Been convicted of driving under the influence of alcohol or drugs?
    Answer only if "yes":

Driver Alcohol Drugs
Yes Yes
Yes Yes
Yes Yes
Yes Yes

4. Been involved in any accidents, regardless of fault, in the past 5 years?
      Yes   No
    If yes, please answer the following:

Driver Date Cost Injuries At Fault Time Description
$ Y
N		 Y
N
$ Y
N		 Y
N
$ Y
N		 Y
N
$ Y
N		 Y
N
Additional Comments:
Please give any additional comments about the coverage you desire:
 

THANK YOU for letting us serve your Automobile Insurance needs.
Your quote will be on its way to you very soon.