>Contact Information

Name*
Address
City*		State*	Select Pennsylvania	Zip:

Please supply either a Daytime or Evening Phone Number and the best time to call.
Day Time Number:
Evening Number: (570)
Best Time To Call*	Select Morning Afternoon Evening
E-mail:*

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Do you currently own your own home*	Select Yes No
Current insurance carrier* (If you do not have a current insurance carrier type in NONE)
How Long*	years
Policy Expiration Date

Driver Information

	Driver1*	Driver2	Driver3
Name*
Sex*	Select Male Female	Select Male Female	Select Male Female
Date of Birth*
Tickets in last 3 years*
Accidents in last 3 years*
Years Licensed*
Daily Commute	miles	miles	miles

Vehicle Information

	Vehicle1*	Vehicle2	Vehicle3
Year*
Make* (i.e. Pontiac)
Model/Trim (i.e. Bonneville)
Body Style (i.e. 2-door)
Cylinders	Select 4 6 8 10 12	Select 4 6 8 10 12	Select 4 6 8 10 12
Passive Restraints*	Select NONE 1 airbag 2 airbags Auto Seatbelts	Select NONE 1 airbag 2 airbags Auto Seatbelts	Select NONE 1 airbag 2 airbags Auto Seatbelts
Anti-Theft Device*	Select None active (i.e. Lo-jack) passive (i.e. Car alarm)	Select None active (i.e. Lo-jack) passive (i.e. Car alarm)	Select None active (i.e. Lo-jack) passive (i.e. Car alarm)
Used for Business	Select Yes No	Select Yes No	Select Yes No
Total Annual Miles
VIN#
Limit of Liability (If other, please specify)	$ Select 15/30K 25/50K 50/100K 100/300K 250/500K other	$ Select 15/30K 25/50K 50/100K 100/300K 250/500K other	$ Select 15/30K 25/50K 50/100K 100/300K 250/500K other
Limit of Property Damage (If other, please specify)	$ Select 5K 10K 25K 50K 100K 250K	$ Select 5K 10K 25K 50K 100K 250K	$ Select 5K 10K 25K 50K 100K 250K
Comprehensive Deductible (If other, please specify	$ Select NONE 50 100 200 250 500 other	$ Select NONE 50 100 200 250 500 other	$ Select NONE 50 100 200 250 500 other
Collision Deductible (If other, please specify	$ Select NONE 100 200 250 500 1000 other	$ Select NONE 100 200 250 500 1000 other	$ Select NONE 100 200 250 500 1000 other
1st Party Medical Expenses (If other, please specify	$ Select 5000 10000 25000 50000 100000 other	$ Select 5000 10000 25000 50000 100000 other	$ Select 5000 10000 25000 50000 100000 other
1st Party Income Loss (If other, please specify	$ Select NONE 1000/5000 1000/15000 1000/25000 2500/50000 5000/100000 other	$ Select NONE 1000/5000 1000/15000 1000/25000 2500/50000 5000/100000 other	$ Select NONE 1000/5000 1000/15000 1000/25000 2500/50000 5000/100000 other
Accidental Death (If other, please specify	$ Select NONE 5000 10000 25000 1000	$ Select NONE 5000 10000 25000 1000	$ Select NONE 5000 10000 25000 1000
Funeral Expenses (If other, please specify	$ Select NONE 1500 2500 other	$ Select NONE 1500 2500 other	$ Select NONE 1500 2500 other
Transportation Expenses (If other, please specify	$ Select NONE 20/day 30/day 35/day other	$ Select NONE 20/day 30/day 35/day other	$ Select NONE 20/day 30/day 35/day other
Uninsured Motorist	$ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000	$ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000	$ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000
Underinsured Motorist	$ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000	$ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000	$ Select NONE 15000/30000 25000/50000 50000/100000 100000/300000 250000/500000
Underinsured/Uninsured Stacking Applies	$ Select stacked unstacked	$ Select stacked unstacked	$ Select stacked unstacked
Tort Option	$ Select limited full	$ Select limited full	$ Select limited full
Road Service	$ Select yes no	$ Select yes no	$ Select yes no

Additional Information:
(If you have any ticket or accidents please explain here
Also provide information about fourth driver and/or vehicle here)

NOTE: All asterisked* fields must be completed for a successful submission. Thanks!

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Paciotti Insurance
320 Main St
Dickson City, PA 18519
(570) 383-3030