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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?
Homeowner:
Vin #:
Vin #:
Leased:
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:
Drivers License Number
Homeowner:
Second Driver's Name:
DOB:
Drivers License Number
Relationship to insured:
Third Driver's Name:
DOB:
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:
PIP:
UM (stacked or non-stacked):  
Rental:
Towing:
Deductibles:  
Collision
Comp:
Rental/Towing