54101 Ironwood Rd
South Bend, IN 46635
(574) 255.6222 Phone • ( 574) 255.6307 Fax
(574) 254-2630 Fax 2

Auto Insurance Questionnaire

All items are required.

Name
Address
City State
Zip
Work Phone
Home Phone
E-Mail
SSN (000/00/0000)
Present Insurance Company
Expiration Date of Present Coverage
Do You Own a Home?
How Long at Present Address (months or years)
Car Year Make Model 2 or 4 door Miles to Work
(one way) 		Annual
Mileage
1
2
3
  Car 1 Car 2 Car 3
Driver Name
Date of Birth
Sex
Marital Status
Occupation
Number of Tickets
in Last Three Years
Number of Accidents
in Last Three Years
Percent of Use      
Car #1
Car #2
Car #3
LIABILITY LIMITS FOR ALL CARS
Choose either Bodily Inury and Property Damage OR Single Limit
Bodily Injury Property Damage Single Limit (Choose One)
Car #1 Deductible Comprehensive Deductible Collision Tow Loss of Use
1
2
3

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