Personal Auto Worksheet

Background Information

Vehicle Information

Auto #1

Auto #2

Auto #3

Auto #4

Insurance Information

Medical insurer
Disabiltiy Insurer
Any comprehensive claims in last 3 years(required)
If yes, please explain why and cost
Have you carried continuous auto insurance for the past 6 months?(required)
If no, please explain
Current Carrier
Policy #
Expiration Date
Current Bodily Injury Limits
How long have you been insured w/your current insurance company?
Do you own a house or condo/rent/or live with a relative?(required)
Who insures the home?(required)
Are you a member of any groups?If yes, please list your memberships here. (ie. AARP, Alumni Assoc., Credit Unions, Home Assoc., Professional Group/Affiliation)

Driver Information

Household Member #1
Name
DOB (Date of Birth)(required)
Sex(required)
Valid License(required)
License # / State
Primary Car Driven / % Driven
Miles Driven (one way)(required)
Occupation
Employer or School Name
Employer or School Address
Accidents (iast 5 years)Please include At Fault, Not At Fault, and/or violations in the last 5 years
Towing
Rental
Comprehensive(required)
Deductible
Collision(required)
Collision Type(required)
Deductible
Household Member #2
Name
DOB (Date of Birth)
Sex
Valid License
License # / State
Primary Car Driven / % Driven
Miles Driven (one way)
Occupation
Employer or School Name
Employer or School Address
Accidents (iast 5 years)Please include At Fault, Not At Fault, and/or violations in the last 5 years
Towing
Rental
Comprehensive
Deductible
Collision
Collision Type
Deductible
Household Member #3
Name
DOB (Date of Birth)
Sex
Valid License
License # / State
Primary Car Driven / % Driven
Miles Driven (one way)
Occupation
Employer or School Name
Employer or School Address
Accidents (iast 5 years)Please include At Fault, Not At Fault, and/or violations in the last 5 years
Towing
Rental
Comprehensive
Deductible
Collision
Collision Type
Deductible