Bills Insurance New Client Info Sheet

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number*

Area CodePhone Number

Secondary Phone Number

Area CodePhone Number

Email*

example@example.com

Do you own or rent your home?*

OwnRent

Is it a mobile home?

YesNo

How long have you lived at this address?*

Previous Address if less than 6 Months

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Level of Education - Some Insurers Provide Education Discounts

Do you currently have auto insurance?*

YesNo

With what company?*

When did you get the policy?*

When does it expire?*

What are your liability (BI-PD) limits?*

What are your comprehensive and collision deductibles?

Do you have Towing and/or Labor or Rental coverage?

YesNo

List ALL members of your household. INCLUDE yourself and anyone age 15 or older, even if they do not drive your vehicle.

Driver 1:

Name*

First NameLast Name

Social Security #*

Driver's License #*

Date of Birth*

MonthDayYear

Sex*

MaleFemale

Marital Status*

Occupation*

Relation to Policy Owner

SpouseChildOther

Add Additional Member

Driver 2:

Name*

First NameLast Name

Social Security #

Driver's License #*

Date of Birth*

MonthDayYear

Sex*

MaleFemale

Marital Status*

Occupation*

Relation to Policy Owner

SpouseChildOther

Add Additional Member

Driver 3:

Name*

First NameLast Name

Social Security #

Driver's License #*

Date of Birth*

MonthDayYear

Sex*

MaleFemale

Marital Status*

Occupation*

Relation to Policy Owner

SpouseChildOther

Add Additional Member

Driver 4:

Name*

First NameLast Name

Social Security #

Driver's License #*

Date of Birth*

MonthDayYear

Sex*

MaleFemale

Marital Status*

Occupation*

Relation to Policy Owner

SpouseChildOther

List all vehicles that you want quoted below with amount of coverage requested:

Year*

Make*

Model*

VIN*

Date of Purchase

Date

Lienholder

Comp Deductible*

Collision Deductible*

Roadside*

YesNo

Rental Car*

YesNo

Is this vehicle used for business?*

YesNo

Add another Vehicle

Year*

Make*

Model*

VIN*

Date of Purchase

Date

Lienholder

Comp Deductible*

Collision Deductible*

Roadside*

YesNo

Rental Car*

YesNo

Is this vehicle used for business?*

YesNo

Add another Vehicle

Year*

Make*

Model*

VIN*

Date of Purchase

Date

Lienholder

Comp Deductible*

Collision Deductible*

Roadside*

YesNo

Rental Car*

YesNo

Is this vehicle used for business?*

YesNo

Add another Vehicle

Year*

Make*

Model*

VIN*

Date of Purchase

Date

Lienholder

Comp Deductible*

Collision Deductible*

Roadside*

YesNo

Rental Car*

YesNo

Is this vehicle used for business?*

YesNo

Have you or any of the household members listed on the previous page ever been involved in ANY TYPE ACCIDENT, even if they were not at fault, or received ANY TICKETS in the past 5 years? If so, list the incident(s), driver and date(s) that the incident(s) occurred:*

Have you or any of the household members listed on the previous page ever been convicted of a felony?

YesNo

Do you understand that we will not cover any loss that occurs while your vehicle is being used in business?*

YesNo

Have all resident of your household been disclosed on this application, including all person age 15 and over; exempt drivers; children away from home or in college and who drive your vehicle on a regular and frequent basis?*

YesNo

Do you understand that we will not cover any loss that occurs while an undisclosed driver or undeclared resident of your household is operating your vehicle?*

YesNo

Are there any other vehicles in your household not listed on this application?*

YesNo

Please provide description:

Driver Name

First NameLast Name

Name of Insurance Carrier

Some companies require that your credit be checked. By filling out this information you give the company the authority to check your credit. All companies will check the following:

*Losses associated with your vehicle
*The status of your driver’s license and your driving history for the last 5 years
*All drivers in your household

Failure to disclose any or all of this information truthfully will jeopardize your coverage.

Electronic Signature*