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April 3, 2017

                                                                               Auto Insurance
Personal Information                                          Date: ______________
Current Auto Insurance?   Yes       No          How long continuous? _________________________________

With whom? ___________________________ Lapsed? Yes       No      When? _____________________

Number in household __________________________ Garaging _________________________________

Are any other policies being written? Yes       No        Residence Type:

Household Members: 9

Term (months): 12

Vehicle Information

#1 Year______ Make_________________ Model_______________ VIN#_________________________

Driven to work? Yes      No       Days driven for work_________________________________________

How Far one way? _______________________ Business / Artisan use? __________________________

Driver name ____________________________ Married? ______ Occupation _____________________

How is vehicle titled? __________________________ DL# _____________________________________

#2 Year______ Make_________________ Model_______________ VIN#_________________________

Driven to work? Yes        No        Days driven for work_________________________________________

How Far one way? _______________________ Business / Artisan use? __________________________

Driver name ____________________________ Married? ______ Occupation _____________________

How is vehicle titled? __________________________ DL# _____________________________________

#3 Year______ Make_________________ Model_______________ VIN#_________________________

Driven to work?  Yes      No      Days driven for work_________________________________________

How Far one way? _______________________ Business / Artisan use? __________________________

Driver name ____________________________ Married? ______ Occupation _____________________

How is vehicle titled? __________________________ DL# _____________________________________

Coverage’s
Prior bodily injury limit: 20/40___ 50/100___ 100/300___ 300/300___ 300/500___ 500/500___

Bodily injury: 20/40___ 50/100___ 100/300___ 300/300___ 300/500___ 500/500___

Uninsured Motorist Limit_______________________ Underinsured Motorist Limit_________________

Medical Insurance covering all household members?   Yes      No        with Whom? _________________

Comprehensive Deductible: $0___ $50___ $100___ $250___ $500___

Collision Deductible: $100___ $250___ $500___ $1000___

Towing?  Yes        No        Limit________________________

During The Past 5 Years
Has any driver in your household had a traffic violation (other than parking)?
Yes        No        If Yes, Provide details;
Driver_______________________________________ Conviction date ___________________________

Description:
_____________________________________________________________________________________
_____________________________________________________________________________________

Has any driver in your household had an At‐Fault accident?
Yes        No        If Yes, provide details;
Driver_______________________________________ Date ____________ Amt. Paid $______________

Description:
_____________________________________________________________________________________
_____________________________________________________________________________________

Any Claims? Yes        No

# Of Not‐At‐Fault accidents___ ____ # of Comprehensive claims______ # over $500? _______________

Has any driver in your household had their license suspended or revoked?  Yes        No

Has any company declined, cancelled or refused to renew insurance for any driver in your household?
Yes        No

Has any driver been convicted of driving while intoxicated or under the influence of drugs? Yes         No

Has any driver been required by any state to file evidence of financial responsibility (SR‐22)? Yes      No

Discounts
Group or membership name? ____________________________________________________________

Pay in Full?   Yes        No

Good Student Discount (3.0 or better)  Yes        No

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