Information About You

Description(s) of your Vehicles

Information About the Driver(s)

* If any of the drivers listed above have been involved in any accidents or been cited for any motor vehicle violations in the past 3 years (INCLUDING NOT-AT-FAULT ACCIDENTS) please describe each event in the box below:

Description of any accidents or violations

Personal  Vehicle Policy Limits & Coverage

Note: Your policy's limits for Liability may be split into separate limits for Bodily Injury per person, Bodily Injury per accident, and Property Damage. Or you may have a Combined Single Limit (CSL) coverage where the limit of the policy is not split. There is a difference in cost, so please choose. Liability limits apply to all vehicles on your policy.

* Bodily Injury Liability Limits (covers injury to others)	Choose limits for Bodily Injury liability $50,000 per person (State Minimum) $100,000 per person, $300,000 each accident $250,000 per person, $500,000 each accident Combined Single Limit (CSL) $125,000 Combined Single Limit (CSL) $300,000
* Property Damage (covers property of others)	Choose limit for Property Damage $25,000 (State Minimum) $50,000 $100,000 each accident I have a CSL policy
* Uninsured/Underinsured Motorists Limits	Choose limit for Uninsured Motorist Liability Minimum as required by Maine $100,000 per person, $300,000 each accident $250,000 per person, $500000 each accident I have a CSL policy
* Medical Payments	Choose limit for Medical Payments $1,000 as Minimum required by Maine $2000 $5,000 $10,000 $25,000
Select the coverage's for damage to your vehicle in the table below (In Maine, the Comp coverage deductible applies to glass damage, i.e. windshield):

Vehicle	Comprehensive  (Other then Collision)	Collision Coverage
#1	No Comp Coverage Full Coverage no deductible $50 deductible $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible	No Collision Coverage Full coverage, no deductible $50 Deductible $100 deductible $250 deductible $500 deductible $1,000 deductible
#2	No Comp Coverage Full Coverage no deductible $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible	No Collision Coverage Full coverage, no deductible $50 Deductible $100 deductible $250 deductible $500 deductible $1,000 deductible
#3	No Comp Coverage Full Coverage no deductible $100 deductible $200 deductible $250 deductible $500 deductible $1,000 deductible	No Collision Coverage Full coverage, no deductible $50 Deductible $100 deductible $250 deductible $500 deductible $1,000 deductible

Optional Coverages: Towing and rental reimbursement limits may apply when one of your insured vehicles becomes disabled.   Please indicate the limits you want to have quoted for the following optional coverage limits:

Additional Vehicle Information

* Have ALL drivers and all vehicles at your household been identified on this form? Yes  No

Please comment below about additional drivers, vehicles or other information you think will help us obtain a more accurate quote for you.  

Additional information  

How did you learn about Equinox?

* Check one of the following to tell us how you heard about Equinox:

A credit union employee or a brochure or flyer from the credit union referenced this Web site.   Employee's Name? A friend or acquaintance referred me here.

* With which Credit Union do you do business? Please select one response from this list Fort Kent Federal Credit Union Houlton Federal Credit Union LaVallee Federal Credit Union NorState FCU(Fraser) St Agatha Federal Credit Union St Francis Community FCU The County Federal Credit Union My Credit Union is NOT LISTED I'm not a Credit Union Member (Affiliated credit unions benefit when members and friends use Equinox services)

Please Read

In order to provide a policy quote some of the companies that we represent may require additional information.  We treat all information that you provide as confidential and that information will be used only for insurance purposes.

By submitting this form, you acknowledge that you have been informed and understand that insurance products offered through Equinox or any affiliate credit union are NOT insured by the NCUA.

You understand and agree that the information gathered here will be used by Equinox Insurance to review your insurance program, send quotes and recommend insurance purchases. You acknowledge that you do not have to accept the quote offered. You have a free choice of insurance agency. You also acknowledge that purchasing or not purchasing insurance from Equinox will not in any way affect any loan decisions.