AUTO QUESTIONNAIRE
AUTOMOBILE
Full Name__________________________________________________________________
Mailing Address_____________________________________________________________
Telephone (Home)___________________________ (Work) _________________________
Employer______________________________ Number of Years Employed ____________
Spouse's Employer______________________ Number of Years Employed _____________
Marital Status_______________________ Homeowner Y N
Driver Information - List all members of household
| | DRIVERS NAME | DATE OF BIRTH | DRIVERS LICENCE #/ STATE | VIOLATIONS/ ACCIDENTS (past 3 years) |
| Driver # 1 | | | | |
| Driver # 2 | | | | |
| Driver # 3 | | | | |
| Driver # 4 | | | | |
Auto Information
| | MAKE/MODEL | YEAR | VEHICLE ID | COST NEW |
| Driver/Car # 1 | | | | |
| Driver/Car # 2 | | | | |
| Driver/Car # 3 | | | | |
| Driver/Car # 4 | | | | |
Airbags ___ Passive Restraints ___ Antilock Brakes ___ Security System ___
Used for (please check one per car)
| | TRAVEL TO/ FROM WORK (LIST MILES - 1 WAY) | PLEASURE/BUSINESS USE (TO/FROM | CLIENT LOCATIONS |
| Driver/Car # 1 | | | |
| Driver/Car # 2 | | | |
| Driver/Car # 3 | | | |
| Driver/Car # 4 | | | |
Prior Insurance Information:
Prior Carrier________________________________ Expiration Date_______________
Coverage Information:
Liability Limits (please circle one)
$25,000/50,000/25,000 $50,000/100,000/50,000 $100,000/300,000/100,000
$250,000/500,000/250,000 $100,000 CSL $300,000 CSL $500,000 CSL
Medical Payments (please circle one) $1,000 $2,000 $5,000 $10,000
Comprehensive Deductible Amount (please circle one)
$00 $50 $100 $200 $250 $500 $1,000
Collision Deductible Amount (please circle one)
$50 $100 $200 $250 $500 $1,000
Uninsured Motorist Coverage Y N Towing and Labor Y N
Rental Reimbursement Y N
Discounts:
Is everyone in household a Non-Smoker? Y N
If there are students in the house: Good student Discount Y N
Drivers Ed Credit Y N