Should you have any questions or any doubt about a change you are contemplating, please call our office during working hours for advice and /or guidance.

    I/We also wish to or not to carry the following:

    Collision (contact with vehicles/property)

    Limited Collision (no more than 50% at fault) No Deductible

    Comprehensive (fire, theft, glass coverage, vandalism, animal contact)

    Auto Loan/Lease Coverage

    New Car Replacement 24 Months (Plymouth Rock Only)

    Original Equipment Manufactured Parts (Plymouth Rock Only)

    Kids Away at School?

    Accident Forgiveness? (must be experienced driver with 99 merit rating)


    Business Use?

    Custom Equipment?

    ** Check carefully that all operators of your auto(s) are listed above.

    My insurance agency/agent M. R. Banas Insurance Agency, Inc has made us aware of the fact that I/We may be underinsured or have no coverage at all in many circumstances of possible claims situations of both liability for bodily injury and/or property damage claim(s). I/We understand once my/our liability limits have been exhausted from a claim for bodily injury I/We am/are liable for my/our own defense costs and pre-judgment interest. ** Once the limits of liability have been exhausted the insurance company’s “Duty To Defend” ends. I/We have read this application in its entirety and I/we declare that to the best of my/our knowledge and belief all of the foregoing statements and answers true with no questions regarding its content. I/We instruct M. R. Banas Insurance Agency, Inc. to submit an application for auto insurance on my/our behalf for the above limits of coverage carefully selected by me/us.

    I agree to the terms above