AUTO INSURANCE QUESTIONNAIRE - RJBlock



AUTO INSURANCE QUESTIONNAIRE

Names of all Drivers

Address

How long have you lived at this address

           

Ages of all drivers

           

Date of birth for all drivers

           

Marital Status

           

Driver license number(s)

            State

            Year Licensed

 

Social Security number(s) (I can take this over the phone if you prefer but I cannot give a quote without it) Why am I being asked this?

Year make and model of all cars

VIN number for all cars

Did you buy them new or used?

Are the vehicles owned free and clear

            Or are they financed or leased

Do you have any anti-theft Devices ( alarm, lojack etc)

Any accidents

            Were you at fault or not at fault?

Were there any claims

            How much was paid

Any violations

            Points (please give details)

 

Do you own a home?

 

Occupation(s)

 

Do you have college degree? (some companies will give a discount for this)

 

How many miles do you drive to work one way?

How many miles do you drive each year?

What company is the current policy with?

How long have you been with the current company?

Do you want full coverage or only liability? 

What is your current premium?

Renewal Date

What was your previous Bodily Injury and personal injury protection coverage ex 50,000/100,000   100,000/300,000    250,000/500,000

What was your previous uninsured motorist coverage ex 50,000/100,000   100,000/300,000    250,000/500,000

Has there been any lapse in coverage?

            If yes please explain

            Please give dates of lapse in insurance

Are any vehicles not registered to the Named Insured?

Has any operator been convicted of a crime resulting from the use of a motor vehicle or been convicted of theft of a motor vehicle?

Has any operator been convicted of fraud or intent to defraud involving an insurance claim or application for insurance?

Has any operator been denied payment of a claim in excess of $1,000 under an auto policy due to fraud/intent to defraud involving a claim/application?

Has any operator knowingly provided materially false/misleading information in connection with an application/renewal/claim under an insurance policy?

Is any household member's driver's license currently suspended or revoked?

Has any company declined or cancelled auto insurance due to non-payment for you or any listed driver in the past 2 years?

Email to rjblock@ or

Fax to RODNEY JACKSON

THE PANGBORN AGENCY

908-668-8140

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