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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