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Automobile Insurance Questionnaire
Agent Name:
Date:
Phone Number:
Email Address:
Client's Name:
First Name:
Last Name:
State of Drivers License:
Date of Birth:
Street Address:
City:
State:
Zip Code:
Ok to run a credit check?
Yes
No
Homeowner:
Yes
No
Vin #:
Vin #:
Leased:
Yes
No
Current Insurance Company:
Policy Number:
Exp Date:
State:
How long:
How many drivers in household:
Does anyone in your household have any of the following?
Please check all that apply.
GMAC auto loan or lease
GMAC mortgage
GMAC or GM employee/retiree
GM dealership employee
GM credit card
First Driver's Name:
DOB:
Male
Female
Single
Married
Drivers License Number
Homeowner:
Second Driver's Name:
DOB:
Male
Female
Single
Married
Drivers License Number
Relationship to insured:
Third Driver's Name:
DOB:
Male
Female
Single
Married
Drivers License Number
Relationship to insured:
Number of Accidents, Tickets, or Claims in last 7 years:
Accidents or Tickets for all drivers:
First Vehicle:
Year:
Make:
Model:
Driver:
Vehicle Use:
Pleasure
Work
Business
School
How many miles one way:
Second Vehicle:
Year:
Make:
Model:
Driver:
Vehicle Use:
Pleasure
Work
Business
School
How many miles one way:
Limits of Liability:
10/20/10
25/50/25
50/100/50
100/300/100
250/500/250
PIP:
10000
UM (stacked or non-stacked):
10/20
25/50
50/100
100/300
250/500
Stacked
Non-Stacked
Rental:
Yes
No
Towing:
Yes
No
Deductibles:
Collision
Comp:
Rental/Towing
