First
name* |
|
MI |
|
Last
name* |
|
Address
* |
|
City* |
|
State* |
|
Zip* |
|
Marital
Status |
|
Best
way to be contacted?* |
|
Phone
number (add area code)* |
|
Best
time to call* |
|
Fax
number |
|
Work
number |
|
E-mail
address * |
|
Occupation |
|
How
long |
|
Additional
Comments: |
|
| |
|
| Requested
Auto Insurance Information |
| |
Current
Insurance Carrier |
|
How
long |
yrs |
Policy
expiration date |
|
Total
years with continuous coverage |
yrs |
| |
|
| Driver
Information |
| |
How
many drivers are in your household? |
|
Name
(primary driver) |
|
Driver
License # |
|
Total
years licensed |
|
Gender |
|
Marital
Status |
|
Occupation |
(if student,
please specify) |
Do
you own your own home |
|
Do
you have health insurance |
|
Date
of birth |
(mm/dd/yyyy) |
Ever
licensed outside of the US or Canada? |
|
#
of accidents in last 3 years |
|
#
of tickets in last 3 years |
|
| |
|
| 2nd
Driver |
| |
2nd
driver name |
|
Relation |
|
Driver
License # |
|
Gender |
|
Marital
Status |
|
Occupation |
(if student,
please specify) |
Own
home? |
|
Do
you have health insurance ? |
|
Date
of birth |
(mm/dd/yyyy) |
Total
years licensed |
|
Ever
licensed outside of the US or Canada? |
|
#
of tickets in last 3 years |
|
#
of accidents in last 3 years |
|
| |
|
| 3rd
Driver |
| |
3rd
driver |
|
Relation |
|
Driver
License # |
|
Gender |
|
Marital
Status |
|
Occupation |
(if student,
please specify) |
Own
home? |
|
Do
you have health insurance? |
|
Date
of birth |
(mm/dd/yyyy) |
Total
years licensed |
|
Ever
licensed outside of the US or Canada? |
|
#
of tickets in last 3 years |
|
#
of accidents in last 3 years |
|
| |
|
Accident Information
Definitions
Most recent
- collision/accident/claims information |
Ticket/Violation
(past 3 years):
Failure to yield or to stop, speeding, etc...
Alcohol/Drug
driving conviction (past 5 years):
DWI, DWAI, DUI, etc...
Collision/Accident
Claim (past 3 years):
Resulting in injury to any person, damage to any vehicle or
structure
Other
than Collision Claim (past 3):
Common losses are - Stereo theft, windshield/Window replacement,
key scratches, fire/water/hail damage, vehicle theft, malicious
mischief, hitting an animal, etc..
If
you do NOT have any of the above, please
continue on to next section. Thank you! |
| |
|
| First
Violation |
| |
Answer
that best describes this incident |
|
Approximate
Date |
(mm/yyyy) |
Name
of the driver involved (if any) |
|
| Amount
paid by your insurance company for property damage or bodily
injury, if any |
Property
Damage: |
$
|
Bodily
Injury: |
$
|
| Briefly
describe the ticket, violation, accident, claim, injury, or
damage if any: |
| |
|
| |
|
| Second
Violation |
| |
Answer
that best describes this incident |
|
Approximate
Date |
(mm/yyyy) |
Name
of the driver involved (if any) |
|
| Amount
paid by your insurance company for property damage or bodily
injury, if any |
Property
Damage: |
$
|
Bodily
Injury: |
$
|
| Briefly
describe the ticket, violation, accident, claim, injury, or
damage if any: |
| |
|
|
|
| Vehicle
Information |
Year
of car |
|
Body
Style |
|
Make |
|
Model |
|
#
of doors |
|
Cylinders |
|
Restraints |
|
Anti-theft
Device |
|
Principal
Operator |
|
Used
for Business |
|
#
of days per week driven to school/work |
|
One-way
daily commute |
miles |
Total
Annual Miles |
|
VIN
# |
|
Property
damage liability |
$
|
Bodily
Injury Liability |
$
|
Comprehensive
deductible |
|
Collision
deductible |
|
Additional
Information: |
|
|
|
