Auto Insurance Intake Form
Starkey Insurance Group
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Prior Insurance Information
Name of Carrier
Monthly Premium
Policy Expiration Date
-
Month
-
Day
Year
Date
Any lapse in coverage?
Yes
No
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Driver's License Number
Driver 1
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
License Number
State of License
Please Select
Valid
Suspended
Expired
Driver's License Number
Driver 2
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
License Number
State of License
Please Select
Valid
Suspended
Expired
Driver's License Number
Driver 3
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
License Number
State of License
Please Select
Valid
Suspended
Expired
Driver's License Number
Driver 4
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
License Number
State of License
Please Select
Valid
Suspended
Expired
Driver's License Number
Driver 5
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
License Number
State of License
Please Select
Valid
Suspended
Expired
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Vehicle Information
Vehicle 1
Year/Make/Model/VIN
Vehicle Usage
Commute
Pleasure
Business
Miles Driven Per Year
Is there a lease/loan on the vehicle?
Yes
No
Vehicle Information
Vehicle 2
Year/Make/Model/VIN
Vehicle Usage
Commute
Pleasure
Business
Miles Driven Per Year
Is there a lease/loan on the vehicle?
Yes
No
Vehicle Information
Vehicle 3
Year/Make/Model/VIN
Vehicle Usage
Commute
Pleasure
Business
Miles Driven Per Year
Is there a lease/loan on the vehicle?
Yes
No
Vehicle Information
Vehicle 4
Year/Make/Model/VIN
Vehicle Usage
Commute
Pleasure
Business
Miles Driven Per Year
Is there a lease/loan on the vehicle?
Yes
No
Vehicle Information
Vehicle 5
Year/Make/Model/VIN
Vehicle Usage
Commute
Pleasure
Business
Miles Driven Per Year
Is there a lease/loan on the vehicle?
Yes
No
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Desired Coverages
Liability Limits
State Minimum
50/100
100/300
UM/UIM
Reject
Match Liability
50/100
100/300
Med Pay
None
$1,000
$5,000
Other
Comprehensive Deductible
$500
$1,000
Collision Deductible
$500
$1,000
Roadside Assistance
Yes
No
Rental Reimbursement
Yes
No
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