Personal Lines Auto Questionnaire
First Name		Middle Name		Last Name
Spouse's First Name		Middle Name		Spouses's Last Name
Address
City		State		Zip Code
Phone No.		Ext.		Email
Present Carrier		Exp. Date		Group Name Group # Member #

Car Information

Veh.	Year	Make & Model	VIN	Titleholder	4 Wheel ABS?	# of Airbags	Type of Alarm
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2
3
4

Car Use

Veh.	Pleasure, Commute, Business	If Commuting, Distance One-Way to Work or School	Garaging Location Address (if different than mailing address above)
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2
3
4

Driver Information (All drivers in household)

Veh.	Name	Sex	DOB	State of License
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3
4

Veh.	Driver's Occupation (i.e.,engineer, homemaker, student)	Employer's or School's Name and Address
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4

Convictions / Accidents / Comprehensive Losses & Non-At-Fault Accidents 5 Years

Driver	Date	Details

Bodily Injury	$20,000/$40,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$1,000,000	Each Person/ Each Accident
Property Damage	$10,000 $25,000 $50,000 $100,000 $250,000 $500,000	Each Occurance
Un/Underinsured Motorist	$20,000/$40,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 $500,000/$1,000,000	Must have a minimum of $50,000 / $100,000 to purchase underinsured
Personal Injury	Full coverage, No Ded Full coverage, $300 Ded Excess Medical	With Excess Medical, type in Major Medical Carrier below

		Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
Comprehensive (Damage to the vehicle not covered by a collision)	Indicate for each vehicle	No Coverage $-0- Ded $50 Ded $100 Ded $250 Ded $500 Ded	No Coverage $-0- Ded $50 Ded $100 Ded $250 Ded $500 Ded	No Coverage $-0- Ded $50 Ded $100 Ded $250 Ded $500 Ded	No Coverage $-0- Ded $50 Ded $100 Ded $250 Ded $500 Ded
No Deductible for Glass Breakage (Not all companies offer this option for an additional cost. Do you want this coverage quoted on this vehicle if available?)	Indicate for each vehicl	Yes, please No thank you	Yes, please No thank you	Yes, please No thank you	Yes, please No thank you
Collision	Indicate for each vehicle	No Coverage $100 Ded $250 Ded $500 Ded $1,000 Dedu	No Coverage $100 Ded $250 Ded $500 Ded $1,000 Ded	No Coverage $100 Ded $250 Ded $500 Ded $1,000 Ded	No Coverage $100 Ded $250 Ded $500 Ded $1,000 Ded
Collision Type:	Indicate for each vehicle	Broad Regular Limited	Broad Regular Limited	Broad Regular Limited	Broad Regular Limited
Towing Road Service	Indicate for each vehicle	No Coverage $50 Limit $100 Limit	No Coverage $50 Limit $100 Limit	No Coverage $50 Limit $100 Limit	No Coverage $50 Limit $100 Limit
Auto Rental Reimbursement	Indicate for each vehicle	No Coverage $20/day $35/day	No Coverage $20/day $35/day	No Coverage $20/day $35/day	No Coverage $20/day $35/day
PIP: Medical Carrier			Wage/Loss Disability Carrier
Total # of Household Family Members			DO YOU WANT A LIFE QUOTE? Yes, please No thank you
Notes to Agent
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