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Personal Auto Quote Questionnaire

Personal Auto Quote Questionnaire

Personal Auto Quote Questionnaire

Date

MM slash DD slash YYYY

Referred By

Applicant 1

First Last

Applicant 1 DOB

MM slash DD slash YYYY

Applicant 2

First Last

Applicant 2 DOB

MM slash DD slash YYYY

Phone Number

Ok to leave a message?

Yes

No

Email Address

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Carried continous auto coverage for past 6 months?

Yes

No

If no, why?

Section Break

Prior Carrier

Expiration Date

How long w/ current insurance?

Claims/Violations last 5 years? Explain

Current Bodily Injury Liability Limit

Vehicle Information

Please submit Year, Make, Model, and Vin # for each

Vehicle 1

Vehicle 1 Comprehensive

Yes

No

Vehicle 1 Collision

Yes

No

Vehicle 1 Comprehensive Deductible

Vehicle 1 Collision Deductible

Vehicle 1 Roadside Coverage

Yes

No

Vehicle 1 Rental Reimbursement

None

$20/day

$30/day

$50/day

Vehicle 1 Primary Operator

Vehicle 1 Usage

Vehicle 2

Vehicle 2 Comprehensive

Yes

No

Vehicle 2 Collision

Yes

No

Vehicle 2 Comprehensive Deductible

Vehicle 2 Collision Deductible

Vehicle 2 Roadside Coverage

Yes

No

Vehicle 2 Rental Reimbursement

None

$20/day

$30/day

$50/day

Vehicle 2 Primary Operator

Vehicle 2 Usage

Vehicle 3

Vehicle 3 Comprehensive

Yes

No

Vehicle 3 Collision

Yes

No

Vehicle 3 Comprehensive Deductible

Vehicle 3 Collision Deductible

Vehicle 3 Primary Operator

Vehicle 3 Usage

Vehicle 2 Roadside Coverage

Yes

No

Vehicle 2 Rental Reimbursement

None

$20/day

$30/day

$50/day

Coverages Desired

PIP

Full Medical/Wge

Excess Medical

Excess Wage

Health Insurance Provider

Wage Continuation Provider

Are an of the vehicles used for delivery or ridesharing?

Yes

No

If so, what are you doing and how often

Drivers

Driver 1 Name

First Last

Driver 1 Date of Birth

MM slash DD slash YYYY

Relationship to Insured

Driver 2 Name

First Last

Driver 2 Date of Birth

MM slash DD slash YYYY

Relationship to Insured

Driver 3 Name

First Last

Driver 3 Date of Birth

MM slash DD slash YYYY

Relationship to Insured

Additinal Information on Applicants

Occupation

Co-Application Occupation

Education

HS Diploma

Some College

Degree

Group Affiliation

AARP, alumni member, medical association, MEA, chamber member, ect

Own or Rent Home

Own

Rent

Would you like a renters quote or home quote?

Yes

No

Any recreational vehicles

Motorcycle, travel trailer, RV, ATV, etc

Discounts Available

Good Student Discount

Student Away at School (without a vehicle and more than 100 miles)

Pay in Full Discount

Multi-Policy Discount

Group Affiliation (Alumni Association, MEA, Senior Association, Chamber of Commerce, etc.)

Low Mileage Discount (less than 8k per year)

Additional Remarks

Location

1793 W Stadium BlvdAnn Arbor, MI 48103

Contact Us

O: 734-327-9222
F: 734-327-9225

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