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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
Address
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?
GMAC auto loan or lease
GMAC mortgage
GMAC or GM employee/retiree
GM dealership employee
GM credit card
First Driver's Name
Date of Birth
Gender
Male
Female
Status
Single
Married
Drivers License Number
Homeowner
Second Driver's Name
Date of Birth
Gender
Male
Female
Status
Single
Married
Drivers License Number
Relationship to insured
Third Driver's Name
Date of Birth
Gender
Male
Female
Status
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
PIP
1000
UM
10/20
25/50
50/100
100/300
250/500
Stacked or Non-stacked)
Stacked
Non-stacked)
Rental
Yes
No
Towing
Yes
No
Deductibles
Collision
Comp
Rental/Towing
Submit
