Deerfield Advisors Insurance Agency
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Auto Insurance Questionnaire
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(281) 550-5864
Auto Insurance Questionnaire
First Name (Primary)
Last Name
Occupation
First Name (Secondary/Spouse)
Last Name
Occupation
Home Phone
Mobile Phone
Work Phone
Email Address
Physical Address
Please indicate your preferred method of communication:
Voice/Phone
Email
Fax
Text
Own or Rent
Own
Rent
Highest Level of Education
GAP / Loan Lease Coverage? (Pays your Creditor in case you total your vehicle within 2 years in some cases)
Yes
No
Driver(s) Info
Driver Name
Date of Birth
Driver License Number
Vehicle(s)
Type
Year
Make
Model
Vin Number
Driving History - Any tickets, accidents or claims in last 5 years? (Please list)
Violations
Year
Accidents
Year
Claims
Year
Approximate Paid Out
At fault?
Yes
No
Vehicle Usage
Work
Pleasure
Miles Driven One Way for Work
Current Insurance
Current Insurance Company
Annual Premium
Policy Expiration Date
Coverages Needed
Liability Only
Full Coverage
Limits Needed
Primary Liability
$25 / $50K
$50 / $100K
$100 / $250K
$250 / $500K
CSL $500K
Uninsured/Underinsured Motorist Coverage
$25 / $50K
$50 / $100K
$100 / $250K
$250 / $500K
CSL $500K
PIP
$2,500
$5,000
Medical Payment
$2,500
$5,000
Comprehensive Deductible
$100
$250
$500
$1000
Collision Deductible
$100
$250
$500
$1000
Rental Reimbursement
Total Loss Replacement
Signature
*
Name
*
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