MICHIGAN! ARE YOU PAYING TOO MUCH FOR INSURANCE??

MICHIGAN! ARE YOU PAYING TOO MUCH FOR INSURANCE??

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. -248-848-1900 Ext. 236 FAX 248-848-1912 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 ________.