MICHIGAN! ARE YOU PAYING TOO MUCH FOR INSURANCE?? in Farmington Hills, Michigan
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Date/Time:26 Sep, 01:44 a.m. EST
Type: Services, For Sale - Private.
Deal with a Michigan based agency, not a lead aggregator for your auto insurance!
-MICHIGAN-AUTO INSURANCE QUOTE QUESTIONNAIRE
Please write clearly and fax, or email when completed. Thank you.
Tel. -248-848-xxxx Ext. 236; FAX 248-848-xxxx ATTN: DAVID- Lic Agent; Date Completed _______
Primary Insured Name:
Home Phone:
Address:
Work Number:
Email Address:
Garaging Address (if different)
Occupation:
Own or Rent your home?
Date of Birth:
Spouse Name:
Address (if different than above):
Alt Phone (i.e. cell)
Email Address:
Garaging Address (if different):
Occupation:
Spouse Date of Birth:
Spouse Work Number
Current Auto Insurance Company:
Renewal Date:
All Drivers living in house:Name/Date of Birth:
1.Name (as it appears on license)_____________________________ License # ________________ DOB:________
2.Name (as it appears on license)_____________________________ License # ________________ DOB_________
3.Name (as it appears on license)_____________________________ License # ________________ DOB__________
4.Name (as it appears on license)_____________________________ License # ________________ DOB___________
Any accidents in last 3 years? Yes or No, if no any accidents in last 6 years? Yes or No
Any minor moving violations (tickets) in last 3 years? Yes or No, if no any moving violations (tickets) in last 6 years? Yes or No
Number of major violations (2 points) in last 3 years? Yes or No, if no, any major violations in last 10 years? Yes or No
Please explain any Yes answers below. Include dates, what happened, type of violation. Be as specific as possible and include whether you were at fault if it was an accident.
Driver # ______________________________________________________________________________________________
Driver # ______________________________________________________________________________________________
Driver # ______________________________________________________________________________________________
Driver # ______________________________________________________________________________________________
VEHICLE INFORMATION-We also insure Motorcycles, Travel Trailers, Boats and Classic Cars!
Yr/Make Model Body Style Miles: Wk/School Vehicle Identification Number Mileage
Car 1 ______________ ______________ ______________ ______________ _______________________________________
Car 2 ______________ ______________ ______________ ______________ _______________________________________
Car 3 ______________ ______________ ______________ ______________ _______________________________________
Car 4 ______________ ______________ ______________ ______________ _______________________________________
Does an anti-theft device protect any of these vehicles? Car No._____ Is the device Manual Automatic VATS Pass Key Other
Any non standard (non factory) installed rims or other enhancements or special paint jobs? If yes, please describe:
Is Homeowners policy with Farmers? Yes or No
Do any cars have air bags? _____________ Which cars? 1 2 3 4
Do any drivers under 25yrs have a "B" average with full time school units? ________Driver (s)________________________
Have any drivers taken a Senior Defensive Driving Course? Driver(s) ______________________
COVERAGES LIMITS:
Bodily Injury Liability (Per Person/Per Accident) ______________ Property Damage_______________
Uninsured /Under Insured Liability _____________________Motorist Medical_______________ (Per Person/Per Accident)
Medical Payments ___________ Mini Tort____________
Comprehensive (Other than Collision) Deductible____________ Collision Deductible__________
Towing/Road Assistance (yes or no) _______
Rental Car Reimbursement (yes or no)_______ if yes, how much per day? ________.
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