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I understand & agree to all of the following

1. No coverage is selected or bound by submitting this form

2. In this form the words Full & Basic are used to describe whether or not you want physical damage included in your quote for that specified vehicle. In no way is does this imply you will or will not have physical damage coverage. A representative will contact you & at that time you select the limits & coverages you would like for your quote.

3. This is not an offer for insurance or coverage

4. You the client are responsible for verifying all information with the representative & correct any inaccurate information

5. This nor any certificate certifies that coverage exists

6. No claim determination is made by submitting this form

7. No claim is started or covered by submitting this form