(Form Below) - GEICO

Instructions

The Vehicle Fire Questionnaire is a written statement you provide to document the details of the fire. To complete this form properly, include your claim number, policy number, date of loss, and fill out all sections.

(Form Below)

GOVERNMENT EMPLOYEES INSURANCE COMPANIES Vehicle Fire Questionnaire

Claim Number Policy Number Date of Loss

Name of Insured/Owner: ______________________________________________ Date of Birth: ___________

Residence Address: ___________________________________________________________________________

P

Street

O Telephone Number: Home: _____________________

City

State

Business: ________________________

Zip Code

L How long have you been at the above residence? ________________________________________________years

I Previous Residence Address: ____________________________________________________________________

C

Street

City

State

Zip Code

Y Employer Name: _________________________________________________________________________________________

H Address: _______________________________________________________________________________________________________________________

O

Street

City

State

Zip Code

L Occupation/Position: _______________________________________________ Length of Service: ___________

D Social Security Number: __________________________________

E Insured's Driver's License Number: _____________________________________ Registered State: ____________

R /

Marital Status:

Single

Married

Divorced

Separated

Widow

O Spouse's Name: ____________________________________________ Date of Birth: __________________

W

Address: (If different from residence address) ________________________________________________________

N

Street

City

State

Zip Code

E

Telephone Number: Home: ______________________

Business: ____________________

R

Employer: ______________________________________________________________________________

Address: _______________________________________________________________________________

I N

Street

City

State

Zip Code

Occupation: _____________________________________________________________________________

F

Spouse's Social Security Number: ___________________________

O

Spouse's Driver's License Number: ________________________________ Registered State: ___________

R

M

Drivers Residing

NAME/RELATION

SEX

DATE OF BIRTH DRIVER'S LICENSE NUMBER

A

In Household

Male

Female

T

Male

Female

I

Male

Female

O

N

Other Vehicles Located

At Residence Address

YEAR

MAKE

MODEL

PLATE NO.

INSURANCE COMPANY

V VEHICLE IDENTIFICATION NUMBER (VIN): ______________________________________________

E

H I C

State: ______________ License Plate Number: ______________________________ Mileage _______________ Year: _____ Make: ______________ Model: ___________________ Color: __________ Special Packages: ___________

L CHECK SPECIFICATIONS AND EQUIPMENT THAT APPLY BELOW:

E Body Style: 2dr

4dr Lift/Hatchback Convertible Wagon Van Pickup Other: _______________

Engine Detail: Size: ________ Cylinders: 3

4

5

6

8

12

Turbo

Diesel

D Transmission: Automatic 6 Speed 5 Speed 4 Speed 3 Speed Optional: Override Overdrive 4 Wheel Drive

E

S C R I P

POWER OPTIONS Pwr Steering Pwr Brakes Pwr Windows

D?COR/CONVENIENCE Air Conditioning Rear Defogger Tilt Wheel

RADIO AM FM Stereo

T

Pwr Locks

Cruise Control

Cassette

I

Pwr Drive Seat

Leather Seats

Seek/Scan

ROOF OPTIONS Vinyl Roof Electric Steel Electric Glass Manual Steel Manual Glass

MOTORCYCLES Headers Full Fairing Plexi-Faring Custom Seat Saddle Bags

O

Pwr Pass Seat

4 Whl Disk Brakes

CB Radio

Flip Roof

Travel Trunk

N

Air Bag

Telescopic Wheel

Telephone

T-Tops

Engine Guard

Anti-Lock Brakes

Auto Load Level

Anti-Theft Device Roof Rack

Case Guard

3rd Seat (wagons only)

CD Player

Soft Top

Back Rest

Wire Wheels

Hard Top

Wire Wheel Cover

- 1 C-221 (03-14) NS

(Continued)

OTHER OPTIONS

V

Step Bumper

E

Sliding Rear Window

H.

Auxiliary Fuel Tank

D

Sport Wheels

E

2-Tone Paint

S

Deluxe 2-Tone Paint

C.

Customizing (Interior/Exterior)

Any Additional Options

Deep Tinted Glass Dual Air Conditioning Running Boards Fog Lights Bedliners Chrome Bed Rails

Trailering Package Eight Passenger Roll Bar Tool Box (Permanent) Grill Guards Positraction

Purchase/Lease Date: _______________

NEW

USED

Purchase Price: $____________

Paid By:

CASH

CHECK

Financed By: _______________________________________

Seller's Name: __________________________________ Telephone Number: ______________________

S

Address: ________________________________________________________________________________

A Tax Paid: $_________________________ Trade In?

NO

YES $_________________________

L Lienholder/Leasing Co. Name: ___________________________________________________________________

E

Address: ________________________________________________________________________________

S

Street

City

State

Zip Code

Telephone Number: ___________________________

D

Account Number: _______________________________ Down Payment: $__________________________

A T

Last Payment: $_________________________________ Date: ___________________________________

A

Has vehicle been repossessed?

NO

YES

Are payments up to date?

YES

NO Lienholder notified of FIRE?

YES

NO

Other outstanding loans?

NO

YES With Whom? _________________________________

Amount? $___________________________________

Owner(s) as shown on title: __________________________________________________________________

S Name of Service Station: ____________________________ Telephone Number: ________________________

E Address of Service Station: ______________________________________________________________________

R

Street

City

State

Zip Code

V Date of Last Service: _____________________ Work Performed: ___________________________________

I List any work performed since purchase other than tune-up, oil, grease: ___________________________________

C ____________________________________________________________________________________________ E When & Where Repaired: _______________________________________________________________________

P Has vehicle been involved in any losses since its purchase?

NO

YES

R Date of Loss: _____________________ Location: _________________________________________________

I Type of Loss: _________________________________________________________________________________

O Damages/Area: _______________________________________________________________________________

R Amount: $____________________________________ Repairs Completed?

NO

YES

D Insurance Company: ___________________________________________________________________________ A Repair Shop Name: _______________________________ Telephone Number: ________________________

M

Address: ________________________________________________________________________________

A

Street

City

State

Zip Code

G Was there any unrepaired body or mechanical damage on the vehicle prior to the fire? NO YES

E If "YES" list damages: ____________________________________________________________________________

F Who had custody of vehicle at the time of the fire? (If other than insured, complete part 1) _____________________ I Exact location of fire: (If subro, complete part 2 ) _____________________________________________________

R Reason car at location: _________________________________________________________________________

E Date and time vehicle last seen before fire: _____________________

____________ A.M.

P.M.

I N

Date and time fire was discovered: _____________________

____________ A.M.

P.M.

F How many set of keys? ______________ Who has extra keys? ________________________________________

O. Are there any keys missing?

NO

YES

Were there any keys in or upon the vehicle?

NO

YES Where? __________________________

Was the vehicle locked?

NO

YES Alarm in use?

NO

YES?

N/A

(Continued)

C-221 (03-14) NS

- 2 -

Briefly describe activity 24 hours prior to fire:

F Briefly describe activity 24 hours after fire: I R E

Have you or any member of your family ever had a vehicle fire?

NO

YES

I If yes, Date: ____________________ Location: _________________ Insurance Company: ________________________

N Do you have any other Insurance on the vehicle?

F

O Do you have a Homeowners

or Tenants

NO Policy?

YES _____________________________________

R Is the vehicle that is reported legally registered and titled at the Department of Motor Vehicles that issued the title and plates?

M

YES

NO

A T

If the identity of the person or persons responsible for the fire of this vehicle is established, are you willing to prosecute that

I person or persons?

YES

NO

O When was your last insurance claim: _____________________

N Name of Company: _______________________________________________________________________________________

P

O Who notified the Fire Dept.?

L __________________________________________________________________________________

I

C Fire Dept.: _________________________ Address: ___________________________________________________________

E

Street

City

State

Zip Code

/ F

Case Number: ___________________ Officer: ____________________________ Badge Number: ___________________

I R

Date and time fire reported: _____________________ Time: _________

A.M.

P.M.

E Fire loss reported to: _____________________________________________ Insurance Company D

E Date _____________________ Time: _______ A.M. P.M.

P T. To Whom ______________________________________________________________________________________________

I

N

F

O.

IF VEHICLE WAS LOANED OR BORROWED:

P Name: __________________________________________________ Telephone Number: _________________________

A Address: _______________________________________________________________________________________________

R

Street

City

State

Zip Code

T Relationship: ___________________ Purpose: ______________________ Does borrower own a vehicle? YES NO

1 If yes: Vehicle Year: ________ Make: ___________ Model: _______________ License Plate Number: _____________

Insurance Company: ________________________________________________________________________________

SUBROGATION:

If the vehicle was parked in a garage or parking lot, identification of place of fire:

P _________________________________________________ A Address: ____________________________________________________________________________________________________ R T Insurance Company: __________________________________________________________________________________________

2 Ticket Number: ______________________________ Lease: _____________________________________

Stub Number: _______________________________ Who parked the car? _____________________________________________

Who was given possession of keys ? Attendant: _____________________________________________________________________

(Continued)

3

C-221 (03-14) NS

IF THERE WERE ANY PERSONAL ITEMS IN YOUR VEHICLE THAT WERE DAMAGED OR DESTROYED

P AND IF YOUR POLICY PROVIDES COVERAGE FOR PERSONAL EFFECTS, PLEASE COMPLETE THIS E SECTION:

R

(LIMIT $200.00)

S

O

LIST ITEMS

N

VALUE OF EACH ITEM

A

L

E

F

F

E

C

T

NOTE: LOSS TO ANY TAPE, WIRE, RECORD DISC OR OTHER MEDIUM FOR USE WITH A DEVICE

S

DESIGNED FOR THE RECORDING AND/OR REPRODUCTION OF SOUND IS NOT COVERED.

(OTHER EXCLUSIONS MAY APPLY)

I swear that the above four (4) pages are true and correct to the best of my knowledge. Name: _______________________________________ Address: _____________________________________ Signature: ____________________________________ Date: ________________________________________

C-221 (03-14) NS

4

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