Personal Auto Insurance Intake Questionnaire

IN ORDER TO PROVIDE AN ACCURATE RATING FOR AN AUTO INSURANCE QUOTE, PLEASE ANSWER THE FOLLOWING QUESTIONS.

Named insured(s):

Named insured (vehicle owner):

Effective date of coverage:

Address:

City:

State:

Zip Code:

Phone:

Email:

Do your currently have a personal Auto policy? If not, why? (Nonpayment, underwriting, new purchase?

If yes what carrier?

Years with carrier:

Do you have AAA and/or AARP?

Do you drive for Lyft, Uber or Door Dash?

How is Premium Paid?

EFT

Paid in full

By Mail

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AUTO POLICY DETAILS:

*All licensed household members should be included, even if they have their own policy.

PLEASE PROVIDE NAME, DATE OF BIRTH, LICENSE NUMBER AND IF GOOD STUDENT DISCOUNT APPLIES.

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Have you been licensed outside of TX?

If so whom, what state and what was the license number?

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VEHICLE(S):

*Please specify: Year, Make, Model, VIN and if Garaging:

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TRAILER- ADDITIONAL QUESTIONS:

Year/Make/Model and VIN (or Homemade)?

Type (boat/utility/dump/etc)

Gross Vehicle Weight (GVW):

Value of Trailer:

Liability only or include collision & comprehensive:

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MOTORCYCLE-ADDITIONAL QUESTIONS:

Year/Make/Model and VIN:

Purchase Price/Value:

CCs:

How many year of experience?

Do you have a motorcycle training certificate:

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RV-ADDITIONAL QUESTIONS:

Year/Make/Model and VIN:

Purchase price/value:

Liability only or include physical damage coverage (collision & comprehensive0:

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*Please be sure to answer all applicable questions to help ensure accurate rating. If you have a current policy and would provide us with a copy it will help expedite the quoting process.

Thank you for choosing us for your Insurance needs!

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Named insured(s):

small business insurance

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Named insured(s):

small business insurance﻿

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