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.
| Question | Answer |
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| Form Name | Automobile Insurance Application |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | auto insurance form, blank insurance declaration page, insurance services organization form auto, insurance application form |
Personal Automobile Insurance Application
Allen Financial Insurance Group •
Please fax completed application along with the declarations page(s) of your current policy
INSURED INFORMATION
Name: |
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Name of |
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Address: |
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City: |
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County: |
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Zip: Rent/Own: |
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Home Phone Number: |
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Business Phone Number: |
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Email Address: |
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DRIVER INFORMATION (Please complete for each driver you want to insure)
Driver 1 |
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Driver 2 |
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Driver 3 |
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Name: |
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Name: |
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Name: |
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Marital Status: |
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Marital Status: |
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Marital Status: |
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Gender: |
Date of Birth: |
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Gender: |
Date of Birth: |
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Gender: |
Date of Birth: |
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Date Licensed: |
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Date Licensed: |
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Date Licensed: |
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Driver’s License Number & State: |
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Driver’s License Number & State: |
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Driver’s License Number & State: |
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Social Security Number: |
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Social Security Number: |
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Social Security Number: |
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VEHICLE INFORMATION (Please complete for each vehicle you want to insure) |
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Vehicle 1 |
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Vehicle 2 |
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Vehicle 3 |
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Vehicle ID Number (VIN): |
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Vehicle ID Number (VIN): |
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Vehicle ID Number (VIN): |
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Year/Make/Model: |
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Year/Make/Model: |
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Year/Make/Model: |
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Annual Mileage: |
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Annual Mileage: |
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Annual Mileage: |
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Usage: |
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Business |
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Pleasure |
Usage: |
Business |
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Pleasure |
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Usage: |
Business |
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Pleasure |
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Carpool |
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Other |
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Carpool |
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Other |
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Carpool |
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Other |
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None |
4 Wheel Standard |
None |
4 Wheel Standard |
None |
4 Wheel Standard |
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Brakes: |
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Brakes: |
Brakes: |
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4 Wheel |
After market |
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4 Wheel |
After market |
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4 Wheel |
After market |
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Air Bag: |
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None |
Driver |
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Air Bag: |
None |
Driver |
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Air Bag: |
None |
Driver |
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Driver & Passenger |
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Driver & Passenger |
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Driver & Passenger |
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None |
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Alarm Only |
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None |
Alarm Only |
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None |
Alarm Only |
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Vehicle Retrieval System |
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Vehicle Retrieval System |
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Vehicle Retrieval System |
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VIN Etching |
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VIN Etching |
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VIN Etching |
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Active Disabling Device |
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Active Disabling Device |
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Active Disabling Device |
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Passive Disabling Device |
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Passive Disabling Device |
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Passive Disabling Device |
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Percentage of Use per Driver: Driver 1 _______ |
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Percentage of Use per Driver: Driver 1 _______ |
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Percentage of Use per Driver: Driver 1 _______ |
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Driver 2 _______ Driver 3 _______ |
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Driver 2 _______ Driver 3 _______ |
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Driver 2 _______ Driver 3 _______ |
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Vehicle Garaged Mailing Address: |
Yes |
No |
Vehicle Garaged Mailing Address: |
Yes |
No |
Vehicle Garaged Mailing Address: |
Yes |
No |
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CURRENT INSURANCE INFORMATION |
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Carrier: |
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Years with Carrier: |
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Bodily Injury Limits: |
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Property Damage Limit: |
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Collision Deductible: |
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Comprehensive Deductible: |
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DRIVING HISTORY Please list ALL accidents and violations for ALL drivers in the last 36 months
Driver: |
Date: |
Type: |
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Driver: |
Date: |
Type: |
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Driver: |
Date: |
Type: |
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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 |
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Signature |
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Date |
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BROKER |
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TELEPHONE ( |
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