Personal Automobile Insurance Review Questionnaire

Personal Automobile Insurance Review Questionnaire

To assist us in protecting against possible uninsured losses, and to keep our information current, please complete the following questionnaire.
Name*

First NameLast Name
Todays Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
To whom is/are the vehicle(s) titled/resgistered?*
Are all owned vehicles listed on the policy?*

YesNo
Is the garaging address listed on your policy correct?*

YesNo
Please list the correct address*
Do you have a vehicle, not owned by you, furnished for your regular use?*

YesNo
If your vehicle is a pick up truck does it have a cap, or camper shell on the back, or other non – factory installed equipment?*

YesNo
Are there any non- household members who regularly use your vehicle?*

YesNo
If your vehicle is financed, is the leinholder properly listed on your policy?*

YesNoN/A
Is your vehicle leased?*

YesNo
Which Vehcile(s)
Do you have a stereo or other electronic device not factory installed?*

YesNo
Is your vehicle used in your business?*

YesNo
Do you haven any signs or advertisements on your vehicle(s)?*

YesNo
Do you drive your vehicle to and from work?*

YesNo
Number of Miles traveled one way
Vehcile 1
Number of days per week
Vehcile 1
Number of Miles traveled one way
Vehcile 2
Number of days per week
Vehcile 2
number of miles driven annually*
Vehcile 1
number of miles driven annually
Vehcile 2
number of miles driven annually
Vehcile 3
number of miles driven annually
Vehcile 4
Do you work in any ride sharing capacity with any company such as Uber or Lyft?*

YesNo
Do you use your vehicle in any capacity of product delivery- i.e. grocieries, food, packages.*

YesNo
Please list all licensed drivers in the household in the spaces provided below.
Driver 1*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Drivers License Number*
Driver 2

First NameLast Name
Date of Birth

MonthDayYear
Date
Drivers License Number
Driver 3

First NameLast Name
Date of Birth

MonthDayYear
Date
Drivers License Number
Driver 4

First NameLast Name
Date of Birth

MonthDayYear
Date
Drivers License Number
Driver 5

First NameLast Name
Date of Birth

MonthDayYear
Date
Drivers License Number
Driver 6

First NameLast Name
Date of Birth

MonthDayYear
Date
Drivers License Number
Please indicate below any children in the household that are approaching driving age:
Please indicate below any changes that you would like to make to any of your coverage:
Bodily Injury Liability Limits*
Property Damage Liability Limits*
Personal Injury Protection Limits:*
Would you be interested in Extended PIP?*

YesNo
Would you be interested in Additional PIP?*

YesNo
Medical Payments Limits*
Uninsured/Underinsured Motorist Limits*
Would you be interested in Stacked Uninsured Motorist Coverage?*

YesNo
Collision Deductible*
Comprehensive Deductible:*
Rental Reimbursement Limits*
Towing & Labor Limits:*
Would you be interested in loan/lease Gap Coverage?*

YesNo
Would you be interested in New Car Replacement Coverage?*

YesNo
If you are a Travelers or SafeCo policy holder, would you be interested in their coverage enhancement endorsement (gives a package of additional coverage)?*

YesNoN/A
If you are a SafeCo or Progressive policy holder, would you be interested in their usage based insurance program (could potentially provide discounts)?*

YesNoN/A
Would you be interested in a quote for Homeowner’s Insuance?*

YesNo
Would you be interested in a quote for Umbrella Liability?*

YesNo
Would you be interested in a quotation for Life, Disability, or Health insurance?*

YesNo
Should be Empty: