Welcome
Your life is full of precious things. The people you love. The home you live in. The car you drive. All of them need to be protected.

Duckworth Insurance Service offers products that will provide the best long-term protection for your family and your lifestyle. Products you need to keep the things you value most in life secure and set your mind at ease.
Home/renters insurance
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Auto insurance
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Flood insurance
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Business insurance
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Life insurance
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    Name : 
    Address : 
    City : 
    State : 
    Zip : 
      E-mail Address : 
    Phone : 
    Fax : 


    Contact Me Via :
    Phone   Fax   E-mail   Postal Mail  


    Auto Information

    Current Auto Insurance   
    Carrier :     
    Homeowner's Insurance   
    Carrier :     


    Desired Liability Limits for All Vehicles

      Auto Liability Coverage (Bodily Injury) :
      

      Auto Liability Coverage (Property Damage) :
      

      Uninsured/Underinsured Motorist Coverage
      (Bodily Injury) :
      

      Uninsured/Underinsured Motorist Coverage
      (Property Damage) (N/A in PA):
      


    Vehicle Information

    Vehicle 1 Vehicle 2 Vehicle 3
    Vehicle ID #:
    Make:
    Model:
    Year:
    Primary Use:
    One-Way Distance to Work:
    Annual Mileage:
    Comprehensive Deductible:
    Collision Deductible:
    Credits: Air Bags
    Anti-Lock Brakes
    Anti-Theft Device
    Automatic Seat Belts    		 Air Bags
    Anti-Lock Brakes
    Anti-Theft Device
    Automatic Seat Belts    		 Air Bags
    Anti-Lock Brakes
    Anti-Theft Device
    Automatic Seat Belts


    Driver Information

    Driver 1 Driver 2 Driver 3
    First Name:
    Last Name:
    Date of Birth
    (00/00/00):
    Gender:
    Marital Status:
    Driving Violations:
    (in past 3 years
    MD/PA, in
    past 5 years WV)    		 Speeding Violations
         # of violations:
    Stop Sign
    Traffic Light
    DUI/DWI
    Reckless Driving
    Failure to Yield
    Other:     		Speeding Violations
         # of violations:
    Stop Sign
    Traffic Light
    DUI/DWI
    Reckless Driving
    Failure to Yield
    Other:     		Speeding Violations
         # of violations:
    Stop Sign
    Traffic Light
    DUI/DWI
    Reckless Driving
    Failure to Yield
    Other:
    Accidents:
    (in past 3 years MD/PA, in past 5 years WV)    		  At Fault       -
     Not at Fault -
     Hit and Run -
     Other          -
          (please explain:)
               		 At Fault       -
     Not at Fault -
     Hit and Run -
     Other          -
          (please explain:)
               		 At Fault       -
     Not at Fault -
     Hit and Run -
     Other          -
          (please explain:)
          




 

 
 
 
Duckworth Insurance Service © 2005