Personal Auto Checklist
Total Page：16
File Type：pdf, Size：1020Kb
PERSONAL AUTO CALL DATE: ______ERIE HOME: ______CURRENT HOME CARRIER: ______RENEWAL DATE: ______HOW DID YOU HEAR ABOUT US? ______
1st NAMED INSURED: ______2nd NAMED INSURED: ______CURRENT ADDRESS: ______HOW LONG______PRIOR ADDRESS: ______HOW LONG ______CONTACT INFO: CELL: ______HOME: ______WORK: ______*EMAIL: ______PRESENTLY INSURED: YES______NO ______CARRIER: ______HOW LONG INSURED: ______DO YOU HAVE ACCIDENT FORGIVENESS: YES______NO ______COVERAGES: BI ______PD ______TORT: FULL______LIMITED ______DED’S: COLL______COMP______LIABILITY ONLY______
DRIVER #1 NAME ______LICENSE # ______STATE: ______YRS LICENSED: ______MARITAL STATUS: ______DOB: ______SSN: ______DRIVING RECORD - IN LAST 5 YRS: AFA: ______VIOLATIONS: ______DUI: ______ARRESTED EVER: ______
DRIVER #2 NAME ______LICENSE # ______STATE: ______YRS LICENSED: ______MARITAL STATUS: ______DOB: ______SSN: ______DRIVING RECORD - IN LAST 5 YRS: AFA: ______VIOLATIONS: ______DUI: ______ARRESTED EVER: ______
AUTO #1 DRIVER: ______VIN # ______YEAR: ______MAKE & MODEL: ______USE: WORK: ______MILES ONE WAY: ______ANNUAL: ______BUSINESS USE: ______PLEASURE: ______ANNUAL: ______ANTI THEFT: ______ANTILOCK BRAKES: ______AIRBAGS: ______LIENHOLDER______
AUTO #2 DRIVER: ______VIN # ______YEAR: ______MAKE & MODEL: ______USE: WORK: ______MILES ONE WAY: ______ANNUAL: ______BUSINESS USE: ______PLEASURE: ______ANNUAL: ______ANTI THEFT: ______ANTILOCK BRAKES: ______AIRBAGS: ______LIENHOLDER______
DRIVER #3 NAME ______LICENSE # ______STATE: ______YRS LICENSED: ______MARITAL STATUS: ______DOB: ______SSN: ______DRIVING RECORD - IN LAST 5 YRS: AFA: ______VIOLATIONS: ______DUI: ______ARRESTED EVER: ______
DRIVER #4 NAME ______LICENSE # ______STATE: ______YRS LICENSED: ______MARITAL STATUS: ______DOB: ______SSN: ______DRIVING RECORD - IN LAST 5 YRS: AFA: ______VIOLATIONS: ______DUI: ______ARRESTED EVER: ______
DRIVER #5 NAME ______LICENSE # ______STATE: ______YRS LICENSED: ______MARITAL STATUS: ______DOB: ______SSN: ______DRIVING RECORD - IN LAST 5 YRS: AFA: ______VIOLATIONS: ______DUI: ______ARRESTED EVER: ______
AUTO #3 DRIVER: ______VIN # ______YEAR: ______MAKE & MODEL: ______USE: WORK: ______MILES ONE WAY: ______ANNUAL: ______BUSINESS USE: ______PLEASURE: ______ANNUAL: ______ANTI THEFT: ______ANTILOCK BRAKES: ______AIRBAGS: ______LIENHOLDER______
AUTO #4 DRIVER: ______VIN # ______YEAR: ______MAKE & MODEL: ______USE: WORK: ______MILES ONE WAY: ______ANNUAL: ______BUSINESS USE: ______PLEASURE: ______ANNUAL: ______ANTI THEFT: ______ANTILOCK BRAKES: ______AIRBAGS: ______LIENHOLDER______