| 1. Date:
Expiration date of your current policy:
Need Coverage By (Date):
|
| 2. Name:
Occupation:
Married?
Single?
|
| 3. Address:
City:
County:
|
| 4. Telephone: Home:
Work:
Mobile:
Fax:
|
| 5. Email:
|
| 6. Date of Birth:
|
| 7: Year licensed:
Miles driven to work (1 way):
|
8. Are you currently insured?
Insured with:
Now paying: $
If yes, we need a copy of your current policy and number of years insured with them. (Proof of Prior Insurance) |
9. Was your policy ever cancelled for Non-Payment or any underwriting reasons?
Date of cancellation:
Details of Cancellation:
|
| 10. Accidents in the past 5 years?
At-Fault:
Not At-Fault:
|
| 11. Accident dates:
Payout:
|
| 12. Moving Violations or Suspensions in last 5 years:
|
13. Comprehensive claims in the last 5 years? (Fire / Theft / Vandalism)
Have you had a vehicle stolen in the last 10 years?
|
14: Year, Make & Model of Vehicle:
Do you own other vehicles?
If yes, Make and Model of Vehicle 2 :
Make and Model of Vehicle 3 :
|
| 15. Is this vehicle used in your business?
Any type of business use?
Description:
|
16. Any customization - special equipment in vehicle? Yes:
No:
If yes, explain:
|
| 17. Do you drive more then 7,500 miles per year? Yes:
No:
| Is your vehicle leased?
|
| 18. Do you own your home or condo?
Rent?
|
| 19. Are there additional drivers in the household? Yes:
No:
If yes, continue on to the next section. If no, proceed to Section 4 below. |
| Section Two: Additional Driver No.1 |
| 20. 1st Additional Drivers Name:
Date of Birth:
Occupation:
|
| 21. Year licensed:
Miles driven to work (1 way):
|
| 22. Year, Make & Model of Vehicle:
|
| 23. Driver has own insurance?
Accidents in the past 5 years?
At-Fault:
Not At-Fault:
|
| 24. Accidents dates:
Payout:
|
| 25. Moving Violations or Suspensions in last 5 years:
|
26. Comprehensive claims in the last 5 years? (Fire / Theft / Vandalism)
Have you had a vehicle stolen in the last 10 years?
|
| 27. Do you drive more then 7,500 miles per year? Yes:
No:
| Is your vehicle leased?
|
| Section Three: Additional Driver No.2 |
| 28. 2nd Additional Drivers Name:
Date of Birth:
Occupation:
|
| 29. Year licensed:
Miles driven to work (1 way):
|
| 30. Year, Make & Model of Vehicle:
|
| 31. Driver has own insurance?
Accidents in the past 5 years?
At-Fault:
Not At-Fault:
|
| 32. Accidents dates:
Payout:
|
| 33. Moving Violations or Suspensions in last 5 years:
|
34. Comprehensive claims in the last 5 years? (Fire / Theft / Vandalism)
Have you had a vehicle stolen in the last 10 years?
|
| 35. Do you drive more then 7,500 miles per year? Yes:
| Is your vehicle leased?
|
| Section Four: Finish |
| 36. Referred by:
Other:
|
| Comments:
|
|
|
|
Reproduction of this Questionnaire is restricted unless permission is given.
|
