Auto Insurance Application

NUMBER OF CARS REGISTERED UNDER THIS DRIVER:
FIRST NAME:
LAST NAME:
PHONE:
ADDRESS:
E-MAIL:
 (ex: yourname@domain.com)
GENDER:
MARITAL STATUS:
RELATION (to primary driver):
DATE OF BIRTH:
DRIVERS LICENSE #:
STATE LICENSED IN (state where license obtained):
LENGTH OF TIME LICENSED (in U.S.):
 Years    Months
LICENSE STATUS:
YEARS OF COVERAGE (continuous coverage):
 (Proof required for discount)
FILING REQUIRED (financial responsibility):
3 YEAR DRIVING RECORD
7 YEARS FOR MAJOR VIOLATIONS
MAJOR VIOLATIONS (DUI, reckless...):
MINOR VIOLATIONS (speeding, failure to stop...):
ACCIDENTS (where you were at fault):
 (Proof required for discount)


























































AUTO INSURANCE - Step 2: VEHICLE INFO
YEAR:
MAKE (example: toyota):
MODEL (example: camry):
SUB-MODEL (example: EX convertible):
VEHICLE IDENTIFICATION # (optional):
ANTI-LOCK BRAKES:
AIR BAGS:
VEHICLE SALVAGED?:
ANTI-THEFT DEVICE?:
PRIMARY DRIVER:
USAGE:
LOCKED GARAGE?:
HOME ZIP (where car parked):
WORK ZIP:
COMMUTE MILEAGE:
 (One way mileage)
ANNUAL MILEAGE:
 (Total annual mileage)
OWNERSHIP:

OWNED
FINANCED
LEASED

 OWNED
FINANCED
LEASED
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
Copyright 2010 BMI Insurance Inc. :: Ben Miller Insurance Agency, Inc, Lic# 0E14637