Auto Worksheet 1
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form questions for a car insurance quote
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Auto Worksheet 1
- 1. AUTO QUOTE WORKSHEET Date _______________ How did your hear about US?_______________________________________ Phone Number __________________________________ Name ______________________________________________ Social Security #_________________________________ DOB ______________ _______________________________________________Social Security #_________________________________ DOB ______________ Driver Lic #___________________________________________ Driver Lic # _____________________________________________________ Address _________________________________________________________ How Long? ________ Previous? ________ City ______________________ County ____________________ Zip ___________ E-mail address?___________________________________ Present Insurer ________________________________________ Premium _______________________ Exp Date _________________________ Why Shopping _________________________________________________________________________________________________________ 3rd driver ___________________________________ DOB ____________ Driver Lic # _______________________ Relationship______________ 4th driver ___________________________________ DOB ____________ Driver Lic # _______________________ Relationship______________ 5th driver ___________________________________ DOB ____________ Driver Lic # _______________________ Relationship______________ Occupation (insured) ________________________________ (how long) _______________ (previous) ____________ (Spouse) ________________________________ (how long) _______________ (previous) ____________ Children?_________________ Ages? _________________ Any driver carpool? ________________________________ Any driver licensed less than 9 years? ___________ Who & how long? ____________________________________________________________ Violations last 5 years? Y or N Who? __________________ What/When? ______________________________________________________________ ____________________ Accidents last 5 years? Y or N Who? __________________ At Fault? Y or N How much paid out? _____________________________________________________________ EVER had DUI RECKLESS DRIVING INSURANCE CANCELLED OR REFUSED When _____________________________ Any drivers AWAY AT SCHOOL GOOD STUDENTS or W/DRIVING TRAINING ___________________________________________ CAR #1 LIMITS Year ________ Make _________________________ Model __________________ _________ BI _________ COMP VIN#____________________________________________________ _________ PD _________ COLL Cost ______________ Sym/ Age _____________ _________ MED _________ RENT Used How? ___________________________________ _________ UM _________ TOW Miles one way _______ Annual Miles ____________________ If You or Your Spouse were on the CAR #2 LIMITS way home from work and some runk Year ________ Make _________________________ Model __________________ crashed through a red light and took _________ BI _________ COMP VIN#____________________________________________________ you or your spouse out of the picture would you want your car to paid off _________ PD _________ COLL Cost ______________ Sym/ Age _____________ Yes No _________ MED _________ RENT Used How? ___________________________________ _________ UM _________ TOW Miles one way _______ Annual Miles ____________________ Pay off ______________ Amount to