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Auto insurance fact finder

VIEWS: 97 PAGES: 1

									Auto insurance fact finder
Titled owner ___________________________________________                    Home phone ______________ Work phone ______________
Address ______________________________________________                      Date current auto policy expires __________________________
City/State/ZIP __________________________________________                   Annual household income $          ___________________________
School _______________________________________________                      Estimate of personal assets $ ___________________________
County _______________________________________________                      Social Security # ______________________________________


               Vehicle 1                                         Vehicle 2                                          Vehicle 3
   Year        Make            Model                 Year        Make               Model               Year        Make            Model



 V.I.N. (Vehicle Identification Number)            V.I.N. (Vehicle Identification Number)             V.I.N. (Vehicle Identification Number)


 Driver # Rental reimbursement? Garage ZIP         Driver # Rental reimbursement? Garage ZIP          Driver # Rental reimbursement? Garage ZIP


   How is this vehicle used? (select one)            How is this vehicle used? (select one)             How is this vehicle used? (select one)
 I Driven to     _____# miles one way              I Driven to        _____# miles one way            I Driven to     _____# miles one way
   work or                                           work or                                            work or
   school          _____# days per week              school           _____# days per week              school        _____# days per week
 I Pleasure use    I Business use                  I Pleasure use    I Business use                   I Pleasure use    I Business use
 ___________ Annual miles                          ___________ Annual miles                           ___________ Annual miles

Comprehensive deductible                           Comprehensive deductible                       Comprehensive deductible
I $250 I $500 I $1,000                             I $250 I $500 I $1,000                         I $250 I $500 I $1,000
Collision deductible         Full Glass            Collision deductible         Full Glass        Collision deductible         Full Glass
I $250 I $500 I $1,000 I yes I no                  I $250 I $500 I $1,000 I yes I no              I $250 I $500 I $1,000 I yes I no
Anti-theft device: I yes I no                      Anti-theft device: I yes I no                  Anti-theft device: I yes I no
ABS: I yes I no                                    ABS: I yes I no                                ABS: I yes I no

                             How much do you feel you could pay out-of-pocket for damage to your car? ____________
Current BI/PD coverage:      Are all members of your household covered by medical insurance? I yes I no
          /
____________________         Does anyone in your household transport others not covered by medical insurance? I yes I no
                             Are all members of your household covered by a motor club? I yes I no

                                            Drivers (List all resident drivers, including yourself)
                                                                                                       At school      Education       Full-time
                                                                                      Certified        more than      Association      student
                  Name/                                     Marital        Years      defensive        100 miles       member?        with B+
 Driver         Occupation             Birthdate     Sex    status       licensed      driver?          away?         Which one?       average
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                                                                 Driving history
 I Check if any driver has been cited for driving while intoxicated or had a license suspended or revoked in the past five years.
 I Check if any driver has had an accident (regardless of fault) or a moving violation in the past five years. If so, complete the
    information below.
  Driver #         Date          Brief description of violation or accident (include damage and dollar amount)




CM-G38511 (3/06)

								
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