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AUTOPEDIA
INSURANCE CHECK-UP FORM
I would like to receive a free quote for vehicle insurance. I understand that I'm not commiting to anything and there is no obligation. This is strictly a request for free information.
  Contact Information
 * All Information Must be Filled Out to Process Your Quote
Name: 
DayTime Phone: 
Address: 
Evening Phone: 
City: 
Email Address: 
State: 
Zip: 
 		Best time to call:  

  Driver Information
Primary Driver's Name: 
Sex: 
male:  female:		# Years Licensed: 
Date of Birth: 
Month:   Day:  Year: 		Marital Status: 
Married:  Single: Divorced:Widowed:
Occupation: 
Miles to work or school: 
If in school, what is your most recentGPA? 
Have you taken Driver's Education? 
yes   no 

Driver #2 Name: 
Sex: 
male:  female:		# Years Licensed: 
Date of Birth: 
Month:   Day:  Year: 		Marital Status: 
Married:  Single: Divorced:Widowed:
Occupation: 
Miles to work or school: 
If in school, what is your most recentGPA? 
Have you taken Driver's Education? 
yes   no 
Driver #3 Name: 
Sex: 
male:  female:		# Years Licensed: 
Date of Birth: 
Month:   Day:  Year: 		Marital Status: 
Married:  Single: Divorced:Widowed:
Occupation: 
Miles to work or school: 
If in school, what is your most recentGPA? 
Have you taken Driver's Education? 
yes   no 
Driver #4 Name: 
Sex: 
male:  female:		# Years Licensed: 
Date of Birth: 
Month:   Day:  Year: 		Marital Status: 
Married:  Single: Divorced:Widowed:
Occupation: 
Miles to work or school: 
If in school, what is your most recentGPA? 
Have you taken Driver's Education? 
yes   no 
Accidents/Tickets inthe last 36 months, including month and year of conviction: 
(Example:  John Doe  AFA-5/97 SPD-1/96)
Driver #1: 
KEY: 
SPD - speeding tickets  
AFA - at fault accident  
NAF - not at fault accident  
DUI - driving under the influence  
DTS - disregard traffic signal  
DWS - driving while suspended  

(Any unlisted violations-please explainin comments) 

Driver #2: 
Driver #3: 
Driver #4: 
  Vehicle Information
Vehicle #1 -   Primary Driver:  
Year: 
Make: 
Model: 
# of doors: 
Turbo: 
yes no		# of air bags: 
none 1  2		    Alarm: 
    yes no
Cylinders: 
ABS: 
yes no		Convertible: 
yes no
 
Vehicle #2 -   Primary Driver:  
Year: 
Make: 
Model: 
# of doors: 
Turbo: 
yes no		# of air bags: 
none 1  2		    Alarm: 
    yes no
Cylinders: 
ABS: 
yes no		Convertible: 
yes no
 
Vehicle #3 -   Primary Driver:  
Year: 
Make: 
Model: 
# of doors: 
Turbo: 
yes no		# of air bags: 
none 1  2		    Alarm: 
    yes no
Cylinders: 
ABS: 
yes no		Convertible: 
yes no
 
Vehicle #4 -   Primary Driver:  
Year: 
Make: 
Model: 
# of doors: 
Turbo: 
yes no		# of air bags: 
none 1  2		    Alarm: 
    yes no
Cylinders: 
ABS: 
yes no		Convertible: 
yes no

  Sport Utility Vehicles
Sport Utility Vehicle #1 -   Primary Driver:  
Year: 
Make: 
Model: 
Extcab: 
yesno		4-Wheel Dr.: 
yesno 		Tonnage: 
# of air bags: 
none 1  2
Cylinders: 
Cost New: 
Customized: 
yesno 		    Alarm: 
    yes no
 
Sport Utility Vehicle #2 -   Primary Driver:  
Year: 
Make: 
Model: 
Excab: 
yesno		4-Wheel Dr.: 
yesno 		Tonnage: 
# of air bags: 
none 1  2
Cylinders: 
Cost New: 
Customized: 
yesno 		    Alarm: 
    yes no

  Additional Information
Are you presently insured?  yesno
If so, with what company? 
How long?  When does your policy expire?
If your policy has lapsed, how longhas it been since you were last covered? 
How long have you lived at your currentresidence? 
How long have you lived at your PREVIOUSresidence? 
Do you:    Own:   Rent:   Live with guardians:
Continuously employed for past 5 years? (multiple employers OK)  yesno
How long have you been with your currentemployer? 
How long have you been with your PREVIOUSemployer? 
Total years in your current profession? 
First job out of high school, college or military?  yesno
Attend colleg/university full time for 2 consecutive years?  yesno
Do you have a Visa, MasterCard, AMEX, or Discover credit card? yes no
Have you filed for bankruptcy in thelast 3 years?   yes no
Any tax liens or judgements in past 3 years?   yes no
Any repossesions, collections or charge-offs more than $100 in past 5 years?   yes no

Are any vehicles used in business?yes no
If yes, list vehicle # and how thevehicle(s) is/are used:  

Are you going to purchase a new car this year?   yes no
If yes, please tell us of the make and model:
Make:
Model:

  Coverages
Your liability (bodily injury and property damage) limits must be the same for all vehicles on your policy. Please indicate the desired limit. You can check your state's minimum coverage requirements here or check your existing policy.Use your brower's back button to return to this form.
Bodily Injury:  
Property Damage: 
Medical Payments:  
Uninsured/Underinsured Motorists:  

COMPREHENSIVE AND COLLISION DEDUCTIBLES:
(Note: The deductable is the amount that you must pay for any covered comprehensive or collision repair claim. The lower the deductable the higher the premium, since the insurance company is assuming greater financial responsibility.)
Vehicle #1 Comprehensive:     Vehicle #1 Collision: 
Vehicle #2 Comprehensive:     Vehicle #2 Collision: 
Vehicle #3 Comprehensive:     Vehicle #3 Collision: 
Vehicle #4 Comprehensive:     Vehicle #4 Collision: 
SUV #1 Comprehensive:     SUV #1 Collision: 
SUV #2 Comprehensive:     SUV #2 Collision: 
TOWING?   yesno
If Yes, Enter Vehicle #s: 

  Comments
Thank you for the opportunity to assist you with your automobile insurance needs. Please double check your entire form BEFORE you hit the SUBMIT below. Please provide any additional information that you think may affect your insurance in the following comments section:

COMMENTS:

  

(Please hit SEND button only once.)


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Last modified 2/5/98. Copyright ©1995-98 by AUTOPEDIA, all rights reserved. AUTOPEDIA™, AUTO411™, CAR-IQ™, DEALERPEDIA™, UNILOT™, SIMULSEARCH™ and INTERQUOTE-RFP™ are trademarks of AUTOPEDIA. All other trademarks, tradenames and/or service marks are the property of their respective holders.