AUTO QUESTIONNAIRE

All items in are necessary for a quote

NAME: ______________________________________________ DATE: ________/______/______

ADDRESS: ________________________________________________________________________

HOME # ___________________  CELL # ___________________  WORK # __________________

EMAIL_________________________________________

How would you like to be contacted when we complete your quote? ___________________

MAY WE CHECK YOUR CREDIT?                   YES                            NO

CURRENT INSURANCE: Company: _________________________  Expires: _____/_____/______

MARITAL STATUS:   S   M   D   W   HOMEOWNER:   YES   NO    # OF DRIVERS _________

DRIVER #1:  Name: ___________________________________ SS# ________-________-________

DOB: ________/________/________  AGE: _________ DL#/STATE: _________________________

OCCUPATION____________________ DEF. DRIVING:     yes     no      DRIVER'S ED:     yes     no

TICKETS (last 3 years):_____________________ CLAIMS (last 3 years):___________________

DRIVER #2  Name: ___________________________________ SS# ________-________-________

DOB: ________/________/________  AGE: _________ DL#/STATE: _________________________

OCCUPATION____________________ DEF. DRIVING:     yes     no     DRIVER'S ED:     yes     no

TICKETS (last 3 years):_____________________ CLAIMS (last 3 years):___________________

DRIVER #3  Name: ___________________________________ SS# ________-________-________

DOB: ________/________/________  AGE: _________ DL#/STATE: _________________________

OCCUPATION____________________ DEF. DRIVING:     yes     no       DRIVER'S ED:     yes     no

TICKETS (last 3 years):_____________________ CLAIMS (last 3 years):___________________

NUMBER OF AUTOS: _________        AUTOS COVERED:      GARAGE     CARPORT    NONE 

#1 MAKE/MODEL: _________________________________________________________________

YEAR MODEL: _________________  VIN: ______________________________________________

LIENHOLDER: _____________________________________________________________________

#2 MAKE/MODEL: _________________________________________________________________

YEAR MODEL: _________________  VIN: ______________________________________________

LIEHOLDER: ______________________________________________________________________

#3 MAKE/MODEL: _________________________________________________________________

YEAR: ________________________  VIN: ______________________________________________

LIENHOLDER: _____________________________________________________________________

BI/PD ____________ UNINSD:_____________ PIP: ____________ COMP/COLL: ____________