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40950 Woodward Ave., Ste 340, Bloomfield Hills, Mi 48304 | (248)549-3519
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PERSONAL INSURANCE
AUTO
HOME
CONDO
RENTER’S
MOTORCYCLE
ATV
BOAT or YACHT
COMMERCIAL INSURANCE
AUTO
LIABILITY and PROPERTY
INDIVIDUAL HEALTH, LIFE, DENTAL
LIFE INSURANCE
DENTAL
HEALTH
GROUP INSURANCE
GROUP HEALTH, LIFE, DENTAL
Customer Service
Personal Insurance Service
Commercial Insurance Service
Claim Reports
Payments
Film Producers
Blog
Find
Home
About Us
Contact Us
Get Quotes
PERSONAL INSURANCE
AUTO
HOME
CONDO
RENTER’S
MOTORCYCLE
ATV
BOAT or YACHT
COMMERCIAL INSURANCE
AUTO
LIABILITY and PROPERTY
INDIVIDUAL HEALTH, LIFE, DENTAL
LIFE INSURANCE
DENTAL
HEALTH
GROUP INSURANCE
GROUP HEALTH, LIFE, DENTAL
Customer Service
Personal Insurance Service
Commercial Insurance Service
Claim Reports
Payments
Film Producers
Blog
Find
~auto quote test
admin
2018-07-31T12:32:04-04:00
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 2
Desired Effective Date
*
Customer Type
*
Personal
Commercial
____________________________________________________________________________________
Insured Name
Marital Status
SSN:
Spouse Name
Spouse SSN:
Current Address, City ST ZIP
Phone
Checkboxes
Home
Cell/Mobile
Work
Email
*
Has insured moved within the last TWO YEARS?
*
Yes
No
Previous Address City, ST ZIP
Insured Birth Date
*
Occupation
(If retired indicate so)
Insured Education
High School Diploma (or GED)
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate
Why Do We Need This:
Total Number of Household Members
(include DRIVERS and NON-DRIVERS)
Spouse?
Yes
No
Spouse Name
Spouse Birth Date
Spouse Occupation
Spuose Education
High School (or GED)
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate
Group Membership? (Alumni, AARP, etc.)
Enter the name of your group or for a List of groups
CLICK HERE
If you find a group that applies, enter the name here.
CURRENT INSURANCE
Do you currently have Auto Insurance?
*
Yes
No
If NO current insurance, is this
New Purchase
Currently Un-Insured
Current Policy Number
Current Insurance Company Name
Current Insurance Expiration Date
Has Your Insurance Ever Been Cancelled or Non-Renewed?
*
Yes
No
If Yes, please explain why
DRIVER INFORMATION
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Driver Name #1 (or Insured)
*
(use "SAME" if same as Name above.)
Driver's License Number #1 (or Insured)
*
License State #1 (or Insured)
*
Birth Date#1 (or Insured)
*
(use "SAME" if same as above.)
Driver Gender #1 (or Insured)
*
Female
Male
Driver Name (Spouse)
(use "SAME" if same as Spouse Name above.)
Driver's License Number (Spouse)
License State (Spouse)
Birth Date (Spouse)
Driver Gender (Spouse)
Female
Male
Number of Additional Drivers
*
0
1
2
3
4
(if more drivers, please put additional driver information in "NOTES" field)
For Additional Drivers we
MUST
have the following information for each:
1. Name
2. Birthdate xx/xx/xxxx
3. License State
4. License Number
5. Gender
6. Marital Status
7. Relationship to Insured
Additonal Driver 1
1. Name 2. Birthdate xx/xx/xxxx 3. License State 4. License Number 5. Gender 6. Marital Status 7. Relationship to Insured
Additional Driver 2
1. Name 2. Birthdate xx/xx/xxxx 3. License State 4. License Number 5. Gender 6. Marital Status 7. Relationship to Insured
Additional Driver 3
1. Name 2. Birthdate xx/xx/xxxx 3. License State 4. License Number 5. Gender 6. Marital Status 7. Relationship to Insured
Additional Driver 4
1. Name 2. Birthdate xx/xx/xxxx 3. License State 4. License Number 5. Gender 6. Marital Status 7. Relationship to Insured
Tickets and Accidents in the last THREE YEARS. (Do not include towing or windshield claims)
We
MUST
have the following information for each:
1. For Both - Driver Name
2. For Both - Incident Date xx/xx/xxxx
3. For Accident - Description
4. For Accident - Insured Driver at Fault (Y or N)
5. For Accident - Amount Paid
6. For Ticket - Type of Ticket Issued
Tickets and/or Accidents, All Drivers
Briefly DESCRIBE any TICKETS or ACCIDENTS in the Last THREE YEARS. Include DRIVER NAME approximate DATE and amount paid for all claims except Towing or Glass.
VEHICLES AND USAGE
Number of Vehicles
*
1
2
3
4
5
6
(if more than FOUR additional drivers please call)
Vehicle 1 Driver Name
*
Vehicle 1 Year, Make, Model and VIN#
*
(VIN # = Vehicle Id Number)
Vehicle Use 1
*
Pleasure