Service Oriented - Solution Driven
973.778.7770
50 Mt Prospect Ave, Clifton NJ 07013
AUTO INSURANCE QUESTIONNAIRE
Select number of drivers :
1
2
3
4
5
AUTO INSURANCE QUESTIONNAIRE
( Step 1 Driver Information )
Driver #1
Name:
Address:
Tel #:
Work #:
Cell #:
Email Address:
Age/Date of Birth:
Marital Status:
Social Security #:
Driver License # & State:
Occupation:
Rent
Own Home
Years Licensed in NJ:
Licensed in another
state/country (where):
Is this your first car:
Yes
No
How were you recommended
Yes
No
to our office?
AUTO INSURANCE QUESTIONNAIRE
( Step 2 Driver Information )
Driver #2
Name:
Age/Date of Birth:
Driver License # & State:
Relationship to applicant:
Occupation:
Years Licensed in NJ:
AUTO INSURANCE QUESTIONNAIRE
( Step 3 Driver Information )
Driver #3
Name:
Age/Date of Birth:
Driver License # & State:
Relationship to applicant:
Occupation:
Years Licensed in NJ:
AUTO INSURANCE QUESTIONNAIRE
( Step 4 Driver Information )
Driver #4
Name:
Age/Date of Birth:
Driver License # & State:
Relationship to applicant:
Occupation:
Years Licensed in NJ:
AUTO INSURANCE QUESTIONNAIRE
( Step 5 Driver Information )
Driver #5
Name:
Age/Date of Birth:
Driver License # & State:
Relationship to applicant:
Occupation:
Years Licensed in NJ:
AUTO INSURANCE QUESTIONNAIRE
( Step 3 Previous Insurance Information )
Previous Insurance Information :
Current Insurance Company:
Policy #:
Effective Dates:
With the same carrier 5+ years:
Yes
No
Less than 3 years:
Yes
No
Current Liability Limits:
or Provide current copy of policy:
Have you had laps in the coverage?
Cancelled
Non-Renewed
Have you had any accidents?
At Fault
Not at Fault
Violations,Suspensions within the last five years? If yes, please provide
Drivers Name :
Date :
Brief description of accidents
and / or Violations :
AUTO INSURANCE QUESTIONNAIRE
( Step 4 Vehicle Information )
Vehicle #1 :
Year:
Make:
Model:
Vin#:
Leased
Financed
Estimated annual miles driven :
Miles driven to work or
school (one way):
Current Odometer Reading :
Principal Operator :
Parked Garage :
Driveway :
Street :
Alarm :
Vehicle #2 :
Year:
Make:
Model:
Vin#:
Leased
Financed
Estimated annual miles driven :
Miles driven to work or
school (one way):
Current Odometer Reading :
Principal Operator :
Parked Garage :
Driveway :
Street :
Alarm :
Vehicle #3 :
Year:
Make:
Model:
Vin#:
Leased
Financed
Estimated annual miles driven :
Miles driven to work or
school (one way):
Current Odometer Reading :
Principal Operator :
Parked Garage :
Driveway :
Street :
Alarm :
Need the following documentation :
Copies of all drivers licenses
Copies of all registrations
Copies of all prior policy(s)
Proff of home owner insurance (for discount)
Proff of insurance for others in household (if applicable)
Copies of Finance/Lease agreement
Copies of Defensive Driving Course Certificate (if applicable)
Note : Company will run a credit score!!!
Applicant Signature :
