Personal Auto - Universal Marketing and management

Proposed Effective DatePlease Note: If quoted greater than 8 days before the effective date a "future effective date" discount may be available. However, that discount will be removed if the policy is not bound 8 days prior to the effective date.

First Name*

Middle Name

Last Name

Date of Birth

Marital Status

Phone

Email*

Address

City

State*

ZIP Code

How long have you been at your current address?

Residence Type

Type of Insurance needed

Reason for Policy

Are all vehicles garaged at home address?

Do you own the Vehicle being quoted?

Have you had any reportable Accidents/Comp Claims/Minor Violations within 5 years or Major Violations in the past 10 years?

If Yes, Please list incidents

Do you authorization to use your Credit Score for quotes?

Social Security Number Status (SS# is used by some carriers to provide a proposal. Please click the ? for more details.)

Social Security NumberIf your state allows it, carriers use credit score to provide you an insurance quote and they use your SS# to pull a credit report. If you do not provide your SS#, you will get a "no hit" insurance quote based upon a middle of the road credit rating.

Do you want this quoted for an annual term if available?(Please note: Choosing a 12 month term could result in a higher premium quoted.)

Expiration Date

Have you had any accidents in the last 5 years

If Yes How Many?

Vehicle Model

Vehicle Make

Vehicle Year

Are you currently insured?

Date of Birth

Driver License Number

Type of Coverage Needed

Driver's License State

License Number

Has this driver's license been suspended or revoked in the last 5 years?

Age when first licensed

Driver's Employment Business/Industry

Occupation

Highest Level of Education

Current Insurance Status

Auto Policy Expiration Date

Prior Liability Coverage Type

Number of Months with this Carrier

Number of Months continuous coverage with ANY Carrier

Has any insurance company cancelled, declined or refused renewal in the past 5 years?

Total number of children living in the home (<18):

Total number of residents living in the home including listed drivers, excluded drivers, children and roommates:

Are all household members listed as drivers?

Does insured qualify for multi-policy credit?

Coverage Level

Liability Coverage Type

Bodily Injury

Property Damage

Uninsured Motorist

Underinsured Motorist

PIP Limit

Additional Personal Injury Protection

Drive Other Car

Vehicle Percentage Use

Is VIN Known?(If Year is prior to 1990, set field to N and select Other for Year)

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Style

Vehicle Ownership?

Vehicle Details

Number Of Doors

Passive Restraint

Vehicle Use

Special Permanently Installed Equipment

Used to Deliver Materials or Supplies or Transport people

Mileage One Way

Days per week vehicle driven to work/school

Vehicle purchased new?

Purchase Date

Anti-Theft

Corporate Owned

Does vehicle have a salvage title?

Odometer Reading

Annual Miles

Vehicle Coverage Level

Comprehensive Deductible

Special Equipment

Tapes/Records/Disks

Electronic Equipment

Excess Sound Repro Equip

Vendor Single Interest

Exclude Liability Coverage from Vehicle?

Comments