Auto Insurance Fact Finder Prepared By:*Alonso, FrancescaAldana, SerigoBalco, CraigBlue, TiffanyD’Hondt, MichaelDiaz, LisaDugan, LeeAnnGodwin, DavidHill, CaitlinHilliard, SherrinHolmes, ShellyJennings, MatthewKennedy, BrewaLamb, KaylaLevi, DouglasLong, TinaLuciano, CarmenLynch, BrookeMella, TonyMitrano, SandraMyers, TamaraNazario, JimmyPeshak, BriannaPirko, PhyllisRhoads, DanRuss, MichaelSalvator, MatthewSaroukos, AnthonySchrack, LeslieShepard, NikkiWilliams-Lewis, NicoleWoods, DarrylYoung, AmyHow did you hear about us?Client InfoClient Name: Client Phone:Client Email:* Preferred Method of ContactPhoneEmailTextClient Address (Street, City, State, Zip)Occupation: Highest Education Level Completed: Home:OwnedRentedLive with ParentsCurrent Policy Info SectionAre you currently insured?YesNo“Please Email Your Current Dec Page to Me at …”Expiration Date: Date Format: MM slash DD slash YYYY Current Insurance Company: Current Premiums: Are Current Premiums:Full PayMonthly PaymentsWhen 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 Drivers1234Name First Last DOB Date Format: MM slash DD slash YYYY Driver's License #: State: Is Driver:FemaleMaleMarital Status:SingleMarriedDivorcedWidowedTickets, accidents, suspensions, or claims w/ the last 5 years?YesNoDetails (Need Date, Amount of Payout, Description of loss or incident)Driver 2Name First Last DOB Date Format: MM slash DD slash YYYY Driver's License #: State: Is Driver:FemaleMaleMarital Status:SingleMarriedDivorcedWidowedTickets, accidents, suspensions, or claims w/ the last 5 years?YesNoDetails (Need Date, Amount of Payout, Description of loss or incident)Driver 3Name First Last DOB Date Format: MM slash DD slash YYYY Driver's License #: State: Driver is:FemaleMaleMarital Status:SingleMarriedDivorcedWidowedTickets, accidents, suspensions, or claims w/ the last 5 years?YesNoDetails (Need Date, Amount of Payout, Description of loss or incident)Driver 4Name First Last DOB Date Format: MM slash DD slash YYYY Driver's License #: State: Driver is:FemaleMaleMarital Status:SingleMarriedDivorcedWidowedTickets, accidents, suspensions, or claims w/ the last 5 years?YesNoDetails (Need Date, Amount of Payout, Description of loss or incident)Vehicle InformationNumber of Vehicles:1234Year: Make: Model: VIN #: Name on Registration/Title: Ownership:FinancedLeasedOwned - No PaymentsFinance Company:Vehicle Use:PleasureTo/From Work or SchoolBusinessAnnual Miles:Miles One Way:Max Radius:Vehicle 2Year: Make: Model: VIN #: Name on Registration/Title: Vehicle 2 Ownership:FinancedLeasedOwned - No PaymentsFinance Company:Vehicle Use:PleasureTo/From Work or SchoolBusinessOne Way Miles: Annual Miles: Max Radius: Vehicle 3Year: Make: Model: VIN #: Name on Registration/Title: Vehicle 3 Ownership:LeasedFinancedOwn - No PaymentsFinance Company:Vehicle Use:PleasureTo/From Work or SchoolBusinessOne Way Miles: Annual Miles: Max Radius: Vehicle 4Year: Make: Model: VIN #: Name on Registration/Title: Vehicle 4 Ownership:LeasedFinancedOwn - No PaymentsFinance Company:Vehicle Use:PleasureTo/From Work or SchoolBusinessOne 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 DeductibleInsuredNamed Insured OnlyNamed Insured & Resident RelativesMedical 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 DeductibleRentalYesNoTowing / RoadsideYesNoTelematics (Usage based rating device, such as Snapshot, Intellidrive, or Righttrack)YesNoUber/LyftYesNoVehicle 2Comprehensive$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleCollision$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleRentalYesNoTowing / RoadsideYesNoTelematicsYesNoUber/LyftYesNoVehicle 3Comprehensive$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleCollision$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleRentalYesNoTowing / RoadsideYesNoTelematicsYesNoUber/LyftYesNoVehicle 4Comprehensive$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleCollision$0 Deductible$250 Deductible$500 Deductible$1,000 DeductibleRentalYesNoTowing / RoadsideYesNoTelematicsYesNoUber/LyftYesNoNotes: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.EmailThis field is for validation purposes and should be left unchanged.
