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|
283 S. Zeeb Rd.,
Suite F Ann Arbor, MI 48103 | |
| Phone: | (734) 213-0880 |
| Fax: | (734) 213-0974 |
|
2140 Grand River
Annex Brighton, MI 48114 | |
| Phone: | (810) 231-8008 |
| For 24-hour emergency claim service, call (800) 435-7764 | |
|
email: tkantola@farmersagent.com | |
| HOURS: Monday through Thursday 9 a.m. to 6:00 p.m. Friday 9a.m. to 5:00 p.m. | |
| File a claim or check your claim status on-line at www.farmers.com | |
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Name | ||
Address | ||
| ||
City | ||
State | ZIP | |
Phone | ||
Date of Birth | (MM/DD/YYYY) | |
| Driver No. 1 | ||
Age | ||
Number of miles one way to work/school | ||
Annual miles | ||
Number of tickets/accidents in the past five years | ||
Month/year ticket(s) received | ||
Type of ticket(s) | ||
| Driver No. 2 | ||
Age | ||
Number of miles one way to work/school | ||
Annual miles | ||
Number of tickets/accidents in the past five years | ||
Month/year ticket(s) received | ||
Type of ticket(s) | ||
| Driver No. 3 | ||
Age | ||
Number of miles one way to work/school | ||
Annual miles | ||
Number of tickets/accidents in the past five years | ||
Month/year ticket(s) received | ||
Type of ticket(s) | ||
| Vehicle No. 1 | ||
VIN # | ||
Year | Make Model | |
| ||
Bodily injury and property damage liability (in thousands) | ||
| 20/40/10 50/100/50 100/300/100 250/500/100 | |
Uninsured motorist liability (in thousands) | ||
| 20/40 50/100 100/300 250/500 | |
| ||
Comprehensive (other than collision) deductible | ||
| 0 $100 $200 $500 | |
Collision deductible | $200.00 $500.00 | |
Type of collision coverage | Standard/regular | |
| Broad | |
| Limited | |
Would you like rental car coverage on this vehicle? Yes No | ||
Would you like towing on this vehicle? Yes No | ||
| Vehicle No. 2 | ||
VIN # | ||
Year | Make Model | |
| ||
Bodily injury and property damage liability (in thousands) | ||
| 20/40/10 50/100/50 100/300/100 250/500/100 | |
Uninsured motorist liability (in thousands) | ||
| 20/40 50/100 100/300 250/500 | |
| ||
Comprehensive (other than collision) deductible | ||
| 0 $100 $200 $500 | |
Collision deductible | $200.00 $500.00 | |
Type of collision coverage | Standard/regular | |
| Broad | |
| Limited | |
Would you like rental car coverage on this vehicle? Yes No | ||
Would you like towing on this vehicle? Yes No | ||
| Vehicle No. 3 | ||
VIN # | ||
Year | Make Model | |
| ||
Bodily injury and property damage liability (in thousands) | ||
| 20/40/10 50/100/50 100/300/100 250/500/100 | |
Uninsured motorist liability (in thousands) | ||
| 20/40 50/100 100/300 250/500 | |
| ||
Comprehensive (other than collision) deductible | ||
| 0 $100 $200 $500 | |
Collision deductible | $200.00 $500.00 | |
Type of collision coverage | Standard/regular | |
| Broad | |
| Limited | |
Would you like rental car coverage on this vehicle? Yes No | ||
Would you like towing on this vehicle? Yes No | ||
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