GHS | individual products

Select a State Below

Personal Information

Name:		(Optional)
Address:		(Optional)
City:
State:
Zip:
County:
Home phone #:		(Optional)
Office phone #:		(Optional)
Length of time at address:

I would like to receive my quote by:
Phone:	Phone #
Mail:	Address
E-mail:	E-mail address

How did you hear about GHS?
Employer:		(Optional)
Years employed there:
Occupation:

Present Coverage

My present insurance company:
My present policy expires:
Years with current carrier:

Driver Information : Please List All Drivers in Household

Driver #	Date of Birth mm/dd/yy	Sex	Marital Status	Year Licensed	Vehicle 1: % of Use	Vehicle 2: % of Use	Vehicle 3: % of Use	Vehicle 4: % of Use	Defensive Driver Course Date
1
2
3
4

Passenger Car and Truck Information - All Vehicles Must be Titled to the Named Insured or Spouse

Vehicle #

Year

Make
(Dodge)

Model
(Shadow)

Body
(4 Door/
Wgn/Trail)

Turbo

Cost New

Driven to
Work or
School

# Miles
One Way

Used in
Business

Used in
Carpool

Days
per Week

Annual
Mileage

Yes
No

Has any driver had a license suspended or revoked?
Is any vehicle equipped with passive restraints?	If yes, Vehicle #s:
Is any vehicle equipped with air bags?	If yes, Vehicle #s:
Is any vehicle equipped with anti-lock brakes?	If yes, Vehicle #s:

Are any of your vehicles parked in the street?	If yes, Vehicle #s:
Is any vehicle not regularly kept at your residence?	If yes, Vehicle #s:

	If yes, garage location - City, State, Zip & Reason:

Accidents:
(Please include information on all accidents, theft, fire, hail, wind, and vandalism losses in the past 3 years. This information is necessary for an accurate quote.)

Driver #s	Loss or Accident Date mm/dd/yy	Loss or Accident Description and Dollar Amount of Damage

Violations: (Please include all violations in the past 3 years.

Driver #s	Violation Date mm/dd/yy	Violation Description (Speeding (how fast?), Stop Light)

Has any company declined, cancelled or refused to renew insurance for any driver during the last three years?
Yes
No

If yes, please indicate which driver(s) and explain:

Driver 1
Driver 2
Driver 3

Explanation:

Have you or a member of your household been convicted of a DWI or DUI?
Yes Date:
No

Coverage Selection:
Please note the coverages below pertain to all vehicles insured through the program.


COVERAGES		OKLAHOMA	TEXAS
Liability	BI (Bodily Injury)	25/50 50/100 100/300 300/500	20/40 25/50 50/100 100/300 300/500
Liability	PD (Property Damage Liability)	25 50 100	15 25 50 100
Liability	UM/UIM (Uninsured Motorist)	10/20 25/50 50/100 100/300 300/500	20/40 25/50 50/100 100/300 300/500
Liability	UM/UIM (Property Damage)	N/A	15 25 50 100
Medical Payments		1,000 2,000 5,000 10,000	500 1,000 2,000 5,000 10,000
Personal Injury Protection	(Texas only)	N/A	2,500 5,000 10,000

Optional Coverages:

Comprehensive (Other than collision)

OKLAHOMA
Veh. #1	Yes No	Deductible
Veh. #2	Yes No	Deductible
Veh. #3	Yes No	Deductible
Veh. #4	Yes No	Deductible

TEXAS
Veh. #1	Yes No	Deductible
Veh. #2	Yes No	Deductible
Veh. #3	Yes No	Deductible
Veh. #4	Yes No	Deductible

Collision

OKLAHOMA
Veh. #1	Yes No	Deductible
Veh. #2	Yes No	Deductible
Veh. #3	Yes No	Deductible
Veh. #4	Yes No	Deductible

TEXAS
Veh. #1	Yes No	Deductible
Veh. #2	Yes No	Deductible
Veh. #3	Yes No	Deductible
Veh. #4	Yes No	Deductible

Towing and Rental Reimbursement

OKLAHOMA - Towing
Veh. #1	Yes No
Veh. #2	Yes No
Veh. #3	Yes No
Veh. #4	Yes No

TEXAS - Towing and Rental Reimbursment
Veh. #1	Yes No	Rental Reimbursment:	Yes No
Veh. #2	Yes No	Rental Reimbursment:	Yes No
Veh. #3	Yes No	Rental Reimbursment:	Yes No
Veh. #4	Yes No	Rental Reimbursment:	Yes No

Has any vehicle been modified or customized to increase its performance or value?
Yes No

If yes, indicate which vehicle and dollar amount:
Vehicle #1	Dollar Amount:
Vehicle #2	Dollar Amount:
Vehicle #3	Dollar Amount:
Vehicle #4	Dollar Amount:

Will you pay your premium through payroll deduction?
Yes No

Do you currently have your homeowners insurance with us?
Yes No

Do you own or rent?
Own Rent