Innovative Risk Services_18-0136-00

Name:

First NameLast Name

Expiration Date:

Date

Email Address:

Policy #:

New Business:

Garaging Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If different from mailing address, please explain:

Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone:

Area CodePhone Number

Cell Phone:

Area CodePhone Number

Work Phone:

Area CodePhone Number

How would you prefer that we contact you and at what general time?

List vehicles on policy:

	Year	Make	Model	VIN#
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4

Do any of the vehicles have anti-theft devices? If YES, which vehicle(s) and what devices(s)?

Are any of the vehicles driven fewer than 7,500 miles per year? Which vehicles?

Are any of the above vehicles a hybrid? If so, which?

Are any of the above vehicles used on a farm? If so, which?

List all drivers in the household:

	Name	License #	Principal Vehicle Driven	Out-of-State License # & Date Received
Person 1
Person 2
Person 3
Person 4

Do any drivers have their own auto policy or are they listed on another policy? List the policyholder name, company and effective date.

Are any drivers to be excluded from a vehicle? If so, which driver and which vehicle?

Have any drivers attended driver training courses? If so, which drivers?

Have any drivers attended Advanced Driver Training Courses? If so, which drivers and which courses? Do you have certificate(s) of completion?

Do any of the household drivers currently attend college? If so, who?

Do any college attendees take a vehicle with them to school? If so, which vehicle?

Where is the college located?

Do any drivers qualify for a Good Student Discount? They must be on a dean’s list, honor roll,have a Grade B or better average, or must be in upper 20% of the class. Which driver(s) are they, and can you supply a report card?

Please list the insurance companies with which your home, umbrella, boat or business policies are placed if they are not with our agency. Account credits may be offered.

Do you belong to any motor club organizations? Please list club and membership number.

Coverage to Be Quoted:

Bodily Injury:

Property Damage:

Uninsured/Underinsured Motorist Bodily Injury:

UM Property Damage:

UM Property Damage Deductible:

Medical Payments:

Comprehensive (Other Than Collision):

Collision:

Road Trouble Service:

Additional Expense (Rental Reimbursement):

Loan/Lease Gap:

YesNo

Comments/Notes:

Each company we work with has their own enhanced coverage. If you are unsure about an option, please put it in the notes above. We will offer the best available coverage when a quote is supplied. Thank you for requested a quote. One of our agents will respond to you as soon as possible.

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