Automobile Insurance Form Details

Insurance is a necessary evil in today's society. It seems like every time you turn around, there's another insurance commercial on TV. And, for the most part, people have to have insurance if they want to drive a car. Driving without auto insurance can result in serious legal consequences. However, understanding automobile insurance and what it covers can be tricky business. This article will help clear up some of the confusion about automobile insurance applications.

The listing contains specifics of the automobile insurance application. You might like to read it prior to completing the gaps.

QuestionAnswer
Form NameAutomobile Insurance Application
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesauto insurance form, blank insurance declaration page, insurance services organization form auto, insurance application form

Form Preview Example

Personal Automobile Insurance Application

Allen Financial Insurance Group • 800-874-9191 • FAX: 602-992-8327 • www.EQGroup.com

Please fax completed application along with the declarations page(s) of your current policy

INSURED INFORMATION

Name:

 

Name of co-applicant:

 

 

 

Address:

 

City:

 

 

 

County:

State:

Zip: Rent/Own:

 

 

 

Home Phone Number:

 

Business Phone Number:

 

 

 

Email Address:

 

 

 

 

 

DRIVER INFORMATION (Please complete for each driver you want to insure)

Driver 1

 

 

 

 

 

Driver 2

 

 

 

 

Driver 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

Name:

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status:

 

 

 

Marital Status:

 

 

 

Marital Status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender:

Date of Birth:

 

 

 

Gender:

Date of Birth:

 

 

 

Gender:

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Licensed:

 

 

 

Date Licensed:

 

 

 

Date Licensed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver’s License Number & State:

 

 

Driver’s License Number & State:

 

 

Driver’s License Number & State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

Social Security Number:

 

 

 

Social Security Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VEHICLE INFORMATION (Please complete for each vehicle you want to insure)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle 1

 

 

 

 

 

Vehicle 2

 

 

 

 

Vehicle 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle ID Number (VIN):

 

 

 

Vehicle ID Number (VIN):

 

 

 

Vehicle ID Number (VIN):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year/Make/Model:

 

 

 

Year/Make/Model:

 

 

 

Year/Make/Model:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Annual Mileage:

 

 

 

Annual Mileage:

 

 

 

Annual Mileage:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Usage:

 

Business

 

Pleasure

Usage:

Business

 

Pleasure

 

Usage:

Business

 

Pleasure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Carpool

 

Other

 

 

Carpool

 

Other

 

 

Carpool

 

Other

 

Anti-lock

 

None

4 Wheel Standard

Anti-lock

None

4 Wheel Standard

Anti-lock

None

4 Wheel Standard

Brakes:

 

Brakes:

Brakes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4 Wheel

After market

 

 

4 Wheel

After market

 

 

4 Wheel

After market

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Air Bag:

 

None

Driver

 

Air Bag:

None

Driver

 

 

Air Bag:

None

Driver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver & Passenger

 

 

Driver & Passenger

 

 

 

Driver & Passenger

 

 

 

 

None

 

Alarm Only

 

 

None

Alarm Only

 

 

None

Alarm Only

 

 

 

Vehicle Retrieval System

 

 

Vehicle Retrieval System

 

 

Vehicle Retrieval System

 

Anti-theft:

 

VIN Etching

 

 

 

Anti-theft:

VIN Etching

 

 

 

Anti-theft:

VIN Etching

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Active Disabling Device

 

 

Active Disabling Device

 

 

Active Disabling Device

 

 

 

Passive Disabling Device

 

 

Passive Disabling Device

 

 

Passive Disabling Device

 

Percentage of Use per Driver: Driver 1 _______

 

Percentage of Use per Driver: Driver 1 _______

 

Percentage of Use per Driver: Driver 1 _______

 

Driver 2 _______ Driver 3 _______

 

 

Driver 2 _______ Driver 3 _______

 

 

Driver 2 _______ Driver 3 _______

 

 

 

 

 

 

 

 

 

 

 

Vehicle Garaged Mailing Address:

Yes

No

Vehicle Garaged Mailing Address:

Yes

No

Vehicle Garaged Mailing Address:

Yes

No

CURRENT INSURANCE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Carrier:

 

 

 

 

 

 

 

 

Years with Carrier:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bodily Injury Limits:

 

 

 

 

 

 

Property Damage Limit:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Collision Deductible:

 

 

 

 

 

 

Comprehensive Deductible:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVING HISTORY Please list ALL accidents and violations for ALL drivers in the last 36 months (At-Fault, Not-at-Fault, Moving Violations, etc.)

Driver:

Date:

Type:

 

 

 

Driver:

Date:

Type:

 

 

 

Driver:

Date:

Type:

 

 

 

INFORMATION RELEASE FORM

As part of the application process in obtaining the insurance coverage you are requesting from licensed insurance carriers of Allen Financial Insurance Group, Inc. and/or it’s licensed carriers may order one or more consumer reports. A consumer report may contain information on credit history, medical conditions, driving records, criminal activity and hazardous sports, among other things.

Under the Fair Credit Reporting Act, Allen Financial Insurance Group, Inc. and/or it’s licensed carriers may review consumer reports to evaluate anyone who applies for this insurance. In the event that coverage is denied to you based wholly or partly on information in a consumer report you will be notified of this fact and given the name and address of the consumer reporting agency making the report.

It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or to the Company until accepted by the Company or Companies but that the information contained herein shall be the basis of the contract should a policy be issued.

WARRANTY

I/We understand and agree that any misstatement of warranty or fact on this application shall be considered a violation of coverage afforded under any policy issued on the basis of this application. I/We understand and agree that this application shall form part of any policy issued.

APPLICANT

 

 

 

 

 

 

Signature

 

 

 

Date

 

 

BROKER

 

 

TELEPHONE (

)

 

 

 

 

 

 

 

 

 

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