Auto Insurance Fact Finder Prepared By:*Alonso, FrancescaBalco, CraigBass, SandyCastellanos, KarimChemaly, MelindaD’Hondt, MichaelJanczak, ShayDugan, LeeAnnHilliard, SherrinKennedy, BrewaKontodiakos, MichaelLamb, KaylaLevi, DouglasLuciano, CarmenMella, TonyPabon, AngelPirko, PhyllisShepard, NikkiValtentin, RoyWoods, DarrylYoung, 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 What Is Most 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.NameThis field is for validation purposes and should be left unchanged.
