Auto Questionnaire

info@chambersbayinsurancesa.com

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(210) 417-4212

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Please fill out the following form. Be sure to upload requested files to expedite your application.

Client Info

Name

Phone

Date of Birth

Address

City

State

Zip

Spouse

Additional Drivers

Vehicle Type

VIN

Make

Model

Body Style

Garaging Zip

How long have you had this vehicle

Primary Vehicle Use

Vehicle used for rideshare/ TNC (Uber, Door Dash, etc.)

Number of Days Commuting

Miles Driven One-Way

Annual Miles

Lienholder

Additional Interest

First Name

Last Name

Marital Status

Relationship

Driver Policy Assignment (property is assigned to primary named insured)

Property Co-Applicant

Date of Birth

Highest Level of Education

Auto Driver Status (rated, excluded, military Deployed)

Driver License Type

License State

Driver’s License number

Age you obtained your license

Employment

Occupation

Distant Student

Good Student

Accidents/Violations

Insured/Spouse has vehicle liability insurance for the past 6 months with no more than 31 days lapse.

Prior Auto Insurance carrier?

Prior Auto Insurance carrier Name

What were the Bodily Injury limits on your most recent policy?

Number of years with your most recent auto insurance carrier?

Have you included all drivers required to be listed within the driver section of this quote?

How many injury claims (PIP) were made in the last 5 years on insurance policies, where any of the drivers listed on this quote were insured?

Prior Liability Limit?

Number of non-weather claims within the past 3 years?

Number of weather claims in the past 3 years?

Number of households residents?

Number of household occupants under the age of 21?

Does the insured own a dog?

Total number of residents living in home included listed drivers, excluded drivers, children and roommates?

Primary Residence

Multi Policy Discount Home/Auto/Renters etc. Choose any additional products that the insured currently has or will purchase in the next month.

info@chambersbayinsurancesa.com

(210) 417-4212

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