Auto Account Information Prepared By:*Alonso, FrancescaDugan, LeeAnnHilliard, SherrinLamb, KaylaLevi, DouglasMella, TonyPirko, PhyllisStevens, JJYoung, AmyHow did you hear about us?Client InfoClient Name: Client Phone:Client Email:* Preferred Method of Contact Phone Email Text Client Address (Street, City, State, Zip)Occupation: Highest Education Level Completed: Home: Owned Rented Live with Parents Wouldn’t it feel good to know you are getting the proper insurance protection & the best possible price?Current Policy Info SectionAre you currently insured? Yes No “Please Email Your Current Dec Page to Me at …”Expiration Date: MM slash DD slash YYYY Current Insurance Company: Current Premiums: Are Current Premiums: Full Pay Monthly Payments When is the last time you heard from your agent?Other than Price, which we know is most important, WHAT else is important to you when shopping your insurance?Driver InformationNumber of Drivers 1 2 3 4 Name First Last DOB MM slash DD slash YYYY Driver's License #: State: Is Driver: Female Male Marital Status: Single Married Divorced Widowed Tickets, accidents, suspensions, or claims w/ the last 5 years? Yes No Details (Need Date, Amount of Payout, Description of loss or incident)Driver 2Name First Last DOB MM slash DD slash YYYY Driver's License #: State: Is Driver: Female Male Marital Status: Single Married Divorced Widowed Tickets, accidents, suspensions, or claims w/ the last 5 years? Yes No Details (Need Date, Amount of Payout, Description of loss or incident)Driver 3Name First Last DOB MM slash DD slash YYYY Driver's License #: State: Driver is: Female Male Marital Status: Single Married Divorced Widowed Tickets, accidents, suspensions, or claims w/ the last 5 years? Yes No Details (Need Date, Amount of Payout, Description of loss or incident)Driver 4Name First Last DOB MM slash DD slash YYYY Driver's License #: State: Driver is: Female Male Marital Status: Single Married Divorced Widowed Tickets, accidents, suspensions, or claims w/ the last 5 years? Yes No Details (Need Date, Amount of Payout, Description of loss or incident)Vehicle InformationNumber of Vehicles: 1 2 3 4 Year: Make: Model: VIN #: Name on Registration/Title: Ownership: Financed Leased Owned - No Payments Finance Company:Vehicle Use: Pleasure To/From Work or School Business Annual Miles:Miles One Way:Max Radius:Vehicle 2Year: Make: Model: VIN #: Name on Registration/Title: Vehicle 2 Ownership: Financed Leased Owned - No Payments Finance Company:Vehicle Use: Pleasure To/From Work or School Business One Way Miles: Annual Miles: Max Radius: Vehicle 3Year: Make: Model: VIN #: Name on Registration/Title: Vehicle 3 Ownership: Leased Financed Own - No Payments Finance Company:Vehicle Use: Pleasure To/From Work or School Business One Way Miles: Annual Miles: Max Radius: Vehicle 4Year: Make: Model: VIN #: Name on Registration/Title: Vehicle 4 Ownership: Leased Financed Own - No Payments Finance Company:Vehicle Use: Pleasure To/From Work or School Business One Way Miles: Annual Miles: Max Radius: Coverage Information SectionBodily Injury/Property Damage Limits:25/50/2525/50/5050/100/2550/100/5050/100/100100/300/50100/300/100250/500/100500/500/100Uninsured Motorists Limits:25/50 Non-Stacked50/100 Non-Stacked100/300 Non-Stacked250/500 Non-Stacked500/500 Non-Stacked10/20 Stacked25/50 Stacked50/100 Stacked100/300 Stacked250/500 Stacked500/500 StackedPersonal Injury Protection: (Recommend $0 Ded, Work Loss Included)$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleInsured Named Insured Only Named Insured & Resident Relatives Medical Payments:None$500$1,000$2,000$5,000$10,000Vehicle Coverage OptionsVehicle 1Comprehensive$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleCollision$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleRental Yes No Towing / Roadside Yes No Telematics (Usage based rating device, such as Snapshot, Intellidrive, or Righttrack) Yes No Uber/Lyft Yes No Vehicle 2Comprehensive$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleCollision$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleRental Yes No Towing / Roadside Yes No Telematics Yes No Uber/Lyft Yes No Vehicle 3Comprehensive$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleCollision$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleRental Yes No Towing / Roadside Yes No Telematics Yes No Uber/Lyft Yes No Vehicle 4Comprehensive$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleCollision$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleRental Yes No Towing / Roadside Yes No Telematics Yes No Uber/Lyft Yes No Notes:We want to let you know how we get paid. We get paid 2 ways, one is a commission that comes from the company directly, not from your pocket & the other, is by referrals from our clients. So if we do a good job for you, we hope that you would consider to refer us to your friends, family & co-workers.Communication Policy I agreeI consent to receiving SMS and/or Email communications relating to this request. By submitting this form, you consent to receive SMS messages and/or emails from our company. To unsubscribe, follow the instructions provided in our communications. Msg & data rates may apply for SMS. Your information is secure and will not be sold to third parties.CommentsThis field is for validation purposes and should be left unchanged.
