Car Insurance Questionnaire
Applicant's Information
Name
Social Security #
Address
City
State
Zip
Years at this address
Previous Address
City
State
Zip
Home Phone
Work Phone
Cell
Drivers License #
State Issued
Sex
Male
Female
Date of Birth
Occupation
Have you had any tickets in the past 5 years?
Yes
No
If yes, provide the following:
Date
Description
Are you an AAA member?
Yes
No
Co-Applicant's Information
Name
Social Security #
Home Phone
Work Phone
Cell
Drivers License #
State Issued
Sex
Male
Female
Date of Birth
Occupation
Have you had any tickets in the past 5 years?
Yes
No
If yes, provide the following:
Date
Description
Vehicle Information
Vehicle 1 Vin #:
Year / Make / Model
Driver of vehicle 1
Daily vehicle use
3-14 Miles
15+ Miles
Pleasure
Business
Vehicle 2 Vin #:
Year / Make / Model
Driver of vehicle 1
Daily vehicle use
3-14 Miles
15+ Miles
Pleasure
Business
Accident Date
Amount Paid
At fault?
Yes
No
Accident description
Accident Date
Amount Paid
At fault?
Yes
No
Accident description
Previous/Current Insurance Company
With company since
Liability
Personal Injury Protection
Uninsured Motorist
Underinsured Motorist
Towing & Labor
Rental Reimbursement
Comp Deductible
Collision Deductible
Student Information
If any young driver, under the age of 25, is still in school & maintains a 3.0 GPA or better, please include a copy of the latest grade report along with name and driver’s license number. If any young driver, under the age of 25, is over 100 miles away from home, attending school, without an insured vehicle, please indicate which driver it is and his/her drivers license number.