Health Insurance Application Vehicle Information Primary Vehicle Year * Make * Model * Drive to Work/School? *YesNo Is Vehicle Leased? *YesNo Work/School Distance *Less than 5 Miles5 Miles10 Miles15 Miles20 Miles30 MilesOver 30 Miles Collision Deductible *No Coverage$100$250$500$1000 Annual Mileage *5,0007,50010,00012,50015,00020,00025,00030,00040,00050,000+ Comprehensive Deduct *No Coverage$100$250$500$1000 Vehicle #2 (if necessary) Year (V2) Make (V2) Model (V2) Used for Commute? (V2) -YesNo Is Vehicle Leased? (V2) -YesNo Work/School Distance (V2)-Less than 5 Miles5 Miles10 Miles15 Miles20 Miles30 MilesOver 30 Miles Collision Deduct. (V2)-No Coverage$100$250$500$1000 Annual Mileage (V2)-5,0007,50010,00012,50015,00020,00025,00030,00040,00050,000+ Comp Deduct. (V2)-No Coverage$100$250$500$1000 Vehicle #3 (if necessary) Year (V3) Make (V3) Model (V3) Used for Commute? (V3) -YesNo Is Vehicle Leased? (V3) -YesNo Work/School Distance (V3)-Less than 5 Miles5 Miles10 Miles15 Miles20 Miles30 MilesOver 30 Miles Collision Deduct. (V3)-No Coverage$100$250$500$1000 Annual Mileage (V3)-5,0007,50010,00012,50015,00020,00025,00030,00040,00050,000+ Comp Deduct. (V3)-No Coverage$100$250$500$1000
