Your Independent Erie Agent for Auto - Home - Business - Life

 

 

  AUTOMOBILE QUOTATION QUESTIONNAIRE
The following form is intended to be a guide for Agents to ask questions of the prospect or insured. It is not considered to be a comprehensive list of questions, but rather a starting point for discussion. It is the Agent's responsibility to ask these and any other questions that are relevant to the prospect's or insured's coverage needs.
  Please type in the ID Number, below, exactly as it appears here:  mt01
* = Required *ID Number :  
    *Name: * Day Phone:

 

 Physical Address:
     (No P.O. Box Addresses)
  City: State: Zip:
  *E-mail Address:
    Auto Checklist Section
    Yes    No  
        1. Are any vehicles titled in your name and leased or loaned to others?
        2. Are any of your vehicles used for business purposes other than driving to and from work?
        3. Do you have a vehicle furnished to you for your regular use?
        4. Are any members of your household students away at school?
        5. Are all licensed drivers in your household listed on your automobile policy?
        6. Do any of your vehicles have customized equipment?
        7. Do any of your vehicles have a custom sound system?
        8. Do you own any recreational vehicles, motor cycles, golf carts or four-wheelers?
        9. Are any of your vehicles equipped with an anti-theft device?
        10. Are any of your vehicles equipped with airbags?
        11. Are any of your vehicles equipped with anti-lock brakes?
        12. Would you like information regarding a Personal Catastrophe Liability policy?
        13. Is your home insured with us?
Homeowner's Renter's
  List all drivers and residents of household:
Name   Sex Date of Birth Driver's License No:
  1.
  2.
  3.
  4.
  5.
  In the last five years, has any driver:
  1.  Been involved in an accident?
No
 Yes
  2.  Been convicted for any traffic violation?
No
 Yes
    3.  Had insurance cancelled for any reason? 
No
 Yes
  4.  Been convicted for operating under the influence?
No
 Yes
  5.  Had their license suspended? 
No
 Yes

  

 6.  Required to file financial responsibility (SR-22) by the State?
No
 Yes
: List All Vehicles
Make/Model Primary Vehicle:
Average Annual Mileage:
  1.
  2.
  3.

 

 Current Insurance Carrier (Not Agent):   
 (Necessary for us to not duplicate current carrier)
  Current Annual Deductible Amount:  Liability Limits: 
  Expiration Date of Current Coverage:
  If not currently insured, how long since you have had auto coverage?
  Are you possibly listed as a driver on any other policy?
  Your Comments:
 

 

Mays Tucker Insurance
Suite 102, 1744 S. Amherst Highway
Amherst, VA 24521-3369
434-946-2131
434-263-8120
Fax: 434-946-9242
Email: maystucker@msn.com

© Copyright 2002 Mays Tucker Insurance. All rights reserved.