Discovery

Washington State Insurance Review

No Obligation to Purchase New Insurance
Are you a AAA Washington Member?*
What date did you become a member?*

MonthDayYear
Date
Would you like be become a member with access to deeper insurance discounts?
Who is your current insurance company?*
Policy Owner - Insured
Legal Name:*
Phone Number*
Is it okay, if your agent communicates via text messaging? *
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is this also the Mailing Address?*

YesNo
How many years have you lived at this address?
Previous Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Licensed Drivers
How many licensed drivers live in the household?*
Driver #1 (INSURED)*
Drivers License Number*
Expiration Date*

MonthDayYear
License Expiration Date
State Licensed In*

Street Address

Street Address Line 2

CityState

Zip Code
Birth Date*

MonthDayYear
Your birth date
Marital Status*
Gender*
Employment*
Occupation?*
For discount purposes
Type of Business?*
Highest level of education?*
Any moving violations in the past 5 years?*
Any accidents, at fault or not in the past 5 years?*
Please explain this accident, including the date?*
Driver #2*

NameDrivers License Number
Expiration Date*

MonthDayYear
License Expiration Date
State Licensed In*

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to Insured?*
Gender*
Employment*
Occupation?*
For discount purposes
Type of Business?*
Birth Date*

MonthDayYear
Your birth date
Highest level of education?*
Any moving violations in the past 5 years?*
Any accidents, at fault or not in the past 5 years?*
Please explain this accident, including the date?*
Driver #3*

NameDrivers License Number
Expiration Date*

MonthDayYear
License Expiration Date
State Licensed In*

Street Address

Street Address Line 2

CityState

Zip Code
Employment*
Occupation?*
For discount purposes
Type of Business?*
Relationship to Insured?*
Gender*
Birth Date*

MonthDayYear
Your birth date
Highest level of education?*
Any moving violations in the past 5 years?*
Any accidents, at fault or not in the past 5 years?*
Please explain this accident, including the date?*
Driver #4*

NameDrivers License Number
Expiration Date*

MonthDayYear
License Expiration Date
State Licensed In*

Street Address

Street Address Line 2

CityState

Zip Code
Relationship to Insured?*
Employment*
Occupation?*
For discount purposes
Type of Business?*
Birth Date*

MonthDayYear
Your birth date
Highest level of education?*
Any moving violations in the past 5 years?*
Any accidents, at fault or not in the past 5 years?*
Please explain this accident, including the date?*
Vehicles
Are any vehicles used for work/business?*
How many vehicles will be insured?*
Vehicle #1 *

MakeModelYear
Usage?*
Daily miles driven? *
Ownership?*
Name of Finance Company?*
Date Purchased*

MonthDayYear
When did you buy?
Purchased New or Used?*
Who drives this vehicle?*
Vehicle #2 *

MakeModelYear
Usage?*
Daily miles driven? *
Ownership?*
Name of Finance Company?*
Date Purchased*

MonthDayYear
When did you buy?
Purchased New or Used?*
Who drives this vehicle?*
Vehicle #3 *

MakeModelYear
Usage?*
Daily miles driven? *
Ownership?*
Name of Finance Company?*
Date Purchased*

MonthDayYear
When did you buy?
Purchased New or Used?*
Who drives this vehicle?*
Vehicle #4 *

MakeModelYear
Usage?*
Daily miles driven? *
Gender*
Ownership?*
Name of Finance Company?*
Date Purchased*

MonthDayYear
When did you buy?
Purchased New or Used?*
Who drives this vehicle?*
Recreational Vehicles

Toys
Please list any recreational vehicles you would like a quote for, such as boats, motorcycles and RV's.
Discounts
Would you like a discount for participating in Telematics? This is when your driving is monitored for 90 days. This discount can be as much as 10% off your premiums. After the 90 days, monitoring stops. *
Any full time students in the household?*
Any voluntary defensive driving classes?*
Home

There are deep discounts for bundling your home and auto insurance with one company.
Do you own or rent your home/apartment?*
When was the last time the roof was replaced?*
What type of rental?*
Is there a Fire Hydrant within 1000 feet of the home? *
Is there a Swimming Pool or Jacuzzi on the property?*
Is there a fence around the Pool/Jacuzzi or is the backyard fenced?*
Is there a trampoline of the property?*
What date does your current coverage expire?*

MonthDayYear
Date
Pets

Dog Breeds
Do you own a dog?*
Type of Dog?*
Notice

On the next page, you will be asked to login to your current insurance carrier. This is required so that we can compare your current coverage and provide savings. Your declarations page will be sent to your AAA Washington Agent. This is a secure connection and no login information is collected. If you have no current insurance, please click next, then close the page.
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Washington State Insurance Review

Policy Owner - Insured

Licensed Drivers

Vehicles

Recreational Vehicles

Discounts

Home

Pets

Notice