Coverage Information
Liability limits for bodily injury & property damage:
Select...
$100,000/$300,000/$50,000
$250,000/$500,000/$100,000
$300,000 combined limit
$500,000 combined limit
DEDUCTIBLES
Vehicle 1
Comp.& Collision
Select..
$100/$250
$100/$500
$100/$1,000
$250/$250
$250/$500
$250/$1,000
$500/$500
$500/$1,000
$1,000/$1,000
Towing Coverage
Rental Reimbursement
Vehicle 2
Comp.& Collision
Select..
$100/$250
$100/$500
$100/$1,000
$250/$250
$250/$500
$250/$1,000
$500/$500
$500/$1,000
$1,000/$1,000
N/A
Towing Coverage
Rental Reimbursement
Vehicle 3
Comp.& Collision
Select..
$100/$250
$100/$500
$100/$1,000
$250/$250
$250/$500
$250/$1,000
$500/$500
$500/$1,000
$1,000/$1,000
N/A
Towing Coverage
Rental Reimbursement
Vehicle 4
Comp.& Collision
Select..
$100/$250
$100/$500
$100/$1,000
$250/$250
$250/$500
$250/$1,000
$500/$500
$500/$1,000
$1,000/$1,000
N/A
Towing Coverage
Rental Reimbursement
Accidents & Violations
In the last 5 years?
Date
Driver
Violation
Select..
Speed under 20 mph
Speed over 20 mph
At fault accident
Non At fault accident
DUI
Reckless driving
Minor not listed
Major not listed
Cost
Select..
Speed under 20 mph
Speed over 20 mph
At fault accident
Non At fault accident
DUI
Reckless driving
Minor not listed
Major not listed
Select..
Speed under 20 mph
Speed over 20 mph
At fault accident
Non At fault accident
DUI
Reckless driving
Minor not listed
Major not listed
Select..
Speed under 20 mph
Speed over 20 mph
At fault accident
Non At fault accident
DUI
Reckless driving
Minor not listed
Major not listed
List any DUI convictions, license suspensions or revocations:
Additional Comments
Please provide any additional comments or information that might be helpful in your quote:
Note: By submitting this form you understand that no coverage is bound until you receive written notice.
Privacy Statement and Credit Scoring
At Zeller Insurance Agency, Inc. we take your personal privacy seriously. We may collect non-publicized personal information about individuals or businesses in the course of doing business. Please read on to understand why and how we collect and use this information, in addition to how we protect the confidentiality of that information.
Information Compilation and Use
We gather and use personal information in order to properly and effectively provide and service our insurance products. For example, we may use nonpublic personal information to underwrite insurance policies, process policy claims, or facilitate various billing procedures.
We may gather information from:
You, on an application or other forms. Information we collect could include names, address, social security number and driver's license numbers.
Your dealings with us, such as payments of premiums or submitting of claims.
Other third parties, such as doctors, employers, and other insurance companies. Information we collect may include medical records, employment history, payment and claim history.
Credit reporting agencies, government agencies, insurance reporting agencies and medical information providers.
Information Disclosure
We do not sell nonpublic information to anyone. We do not disclose nonpublic personal information to our affiliates or to any nonaffiliated third parties, except as required by law.
Thank you for choosing Zeller Insurance Agency, Inc. We appreciate the trust that you place with us. We value your business and appreciate the opportunity to service your insurance needs today and in the future.
