AUTOPEDIA™: Insurance Check-Up Form

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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. All information submitted will be kept confidential.
APPLICANT INFORMATION (Person filling out this form.)
Name
Street
City
State		Zip
Home Phone
Business Phone
Email Address
Preferred Method of Response	Telephone Email (Note: Telephone response is faster.)
Note: Unless you have 4 drivers and 4 vehicles in your household, this form is not nearly as long or complicated as it first appears. If you DO have 4 drivers and 4 vehicles in your household, then you are probably accustomed to long forms anyway.

HOUSEHOLD DRIVER INFORMATION

DRIVER #1 (This is usually the applicant.)

Name

Occupation

Date of Birth

Marital Status Sex

# Years Licensed Miles to
Work/School

Most Recent GPA Driver's
Education

DRIVER #2

Name

Occupation

Date of Birth

Marital Status Sex

# Years Licensed Miles to
Work/School

Most Recent GPA Driver's
Education

DRIVER #3

Name

Occupation

Date of Birth

Marital Status Sex

# Years Licensed Miles to
Work/School

Most Recent GPA Driver's
Education

DRIVER #4

Name

Occupation

Date of Birth

Marital Status Sex

# Years Licensed Miles to
Work/School

Most Recent GPA Driver's
Education

VEHICLE INFORMATION

PASSENGER CAR AND TRUCK INFORMATION

VEHICLE #1 #2 #3

YEAR

MAKE

MODEL

TYPE

# OF DOORS

CONVERTIBLE? Yes Yes Yes

CYLINDERS

TURBO-CHARGER? Yes Yes Yes

DRIVER AIR BAG? Yes Yes Yes

PASSENGER AIR BAG? Yes Yes Yes

ANTI LOCK BRAKES
(ABS) Yes Yes Yes

ANTI-THEFT DEVICE?
(Alarm, Lo-Jack) Yes Yes Yes

VEHICLE USED
IN BUSINESS? Yes Yes Yes

PRIMARY DRIVER

ESTIMATED ANNUAL
MILEAGE

RECREATIONAL VEHICLE INFORMATION
(Motor Home · Camper · Trailer · Van Conversion)

VEHICLE #4

YEAR

BODY (Motor Home, Van)

MAKE (Winnebago, Starcraft)

MODEL (Chieftan, Sundance)

LENGTH

DATE PURCHASED

PURCHASE PRICE

PURCHASED NEW OR USED? New Used

CURRENT MARKET VALUE

STATE OF REGISTRATION

ESTIMATED ANNUAL MILEAGE

DRIVEN TO WORK OR SCHOOL? Yes

PRIMARY DRIVER

TICKET AND ACCIDENT INFORMATION

ACCIDENT & TRAFFIC VIOLATION HISTORY

Has any driver had their
license revoked? Yes If yes, who, when and why?

Any moving violations or
accidents in the past 3 yrs? Yes If there have been moving violations or accidents, please describe below.

Driver Date Amount of
Damage Type** Anyone Injured?

$ Yes

$ Yes

$ Yes

$ Yes

**Type Definitions: SPD = Speeding Ticket; AFA = At Fault Accident; NAF = Not At Fault Accident; DUI = Driving Under the Influence; DTS = Disregard Traffic Signal; DWS = Driving While Suspended.

ADDITIONAL INFORMATION

ADDITIONAL APPLICANT INFORMATION

Are you presently insured? Yes No Insurance Company Name:

Current Policy Expires:

If your policy has lapsed, how long
since you were last covered?

Do you: Own your home Rent Live with guardians

How long at present address?

Your Occupation: Spouse's Occupation:

Years with current employer: You Spouse

Years with previous employer: You Spouse

Do you have a major credit card? Yes No

Have you filed for bankruptcy
in the last 3 years? Yes No

Are you planning on purchasing
a new car or truck this year? Yes No If yes, which make and model?

POLICY COVERAGE

LIABILITY
Your liability limits must be the same for all vehicles on your policy. Please indicate the desired limits.
You can check your state's minimum coverage requirements here or check your existing policy.
Use brower back button to return to this form.

Bodily Injury:

Property Damage:

Medical Payments:

Uninsured/Underinsured Motorists:

DEDUCTABLES FOR COMPREHENSIVE & COLLISION
(Note: The deductable is the amount that you must pay for any covered claim. The lower the deductable the higher the premium, since the insurance company is assuming greater financial responsibility.)

VEHICLE #1: TOWING? Yes No

VEHICLE #2: TOWING? Yes No

VEHICLE #3: TOWING? Yes No

VEHICLE #4: TOWING? Yes No

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.)

Last modified 12/10/97. Copyright ©1995-2001 by AUTOPEDIA, all rights reserved. AUTOPEDIA™, AUTO411™, CAR-IQ™, DEALERPEDIA™, INTERLOT™, SIMULSEARCH™ and INTERQUOTE-RFP™ are trademarks of AUTOPEDIA. All other trademarks, tradenames and/or service marks are the property of their respective holders.

DRIVER #1 (This is usually the applicant.)
Name
Occupation
Date of Birth
Marital Status		Sex
# Years Licensed		Miles to Work/School
Most Recent GPA		Driver's Education

DRIVER #2
Name
Occupation
Date of Birth
Marital Status		Sex
# Years Licensed		Miles to Work/School
Most Recent GPA		Driver's Education

DRIVER #3
Name
Occupation
Date of Birth
Marital Status		Sex
# Years Licensed		Miles to Work/School
Most Recent GPA		Driver's Education

DRIVER #4
Name
Occupation
Date of Birth
Marital Status		Sex
# Years Licensed		Miles to Work/School
Most Recent GPA		Driver's Education

PASSENGER CAR AND TRUCK INFORMATION
VEHICLE	#1	#2	#3
YEAR
MAKE
MODEL
TYPE
# OF DOORS
CONVERTIBLE?	Yes	Yes	Yes
CYLINDERS
TURBO-CHARGER?	Yes	Yes	Yes
DRIVER AIR BAG?	Yes	Yes	Yes
PASSENGER AIR BAG?	Yes	Yes	Yes
ANTI LOCK BRAKES (ABS)	Yes	Yes	Yes
ANTI-THEFT DEVICE? (Alarm, Lo-Jack)	Yes	Yes	Yes
VEHICLE USED IN BUSINESS?	Yes	Yes	Yes
PRIMARY DRIVER
ESTIMATED ANNUAL MILEAGE

ACCIDENT & TRAFFIC VIOLATION HISTORY
Has any driver had their license revoked?	Yes	If yes, who, when and why?
Any moving violations or accidents in the past 3 yrs?	Yes	If there have been moving violations or accidents, please describe below.
Driver		Date	Amount of Damage	Type**		Anyone Injured?
			$		Yes
			$		Yes
			$		Yes
			$		Yes
Type Definitions: SPD = Speeding Ticket; AFA = At Fault Accident; NAF = Not At Fault Accident; DUI = Driving Under the Influence; DTS = Disregard Traffic Signal; DWS** = Driving While Suspended.

ADDITIONAL APPLICANT INFORMATION
Are you presently insured?	Yes No	Insurance Company Name:
Current Policy Expires:
If your policy has lapsed, how long since you were last covered?
Do you:	Own your home Rent Live with guardians
How long at present address?
Your Occupation:		Spouse's Occupation:
Years with current employer:	You Spouse
Years with previous employer:	You Spouse
Do you have a major credit card?	Yes No
Have you filed for bankruptcy in the last 3 years?	Yes No
Are you planning on purchasing a new car or truck this year?	Yes No	If yes, which make and model?

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

DEDUCTABLES FOR COMPREHENSIVE & COLLISION (Note: The deductable is the amount that you must pay for any covered claim. The lower the deductable the higher the premium, since the insurance company is assuming greater financial responsibility.)
VEHICLE #1:	TOWING?	Yes No
VEHICLE #2:	TOWING?	Yes No
VEHICLE #3:	TOWING?	Yes No
VEHICLE #4:	TOWING?	Yes No