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Automobile / Cycle / Boat Quotation Questionnaire 

Date: (MM/DD/YY)    Phone: (Home)    (Work)   

Address Information: 

Street/ No PO Box:    City:  State:    Zip:   

How Long Have You Lived At Your Current Address:   

If Less Than 6 Months Give Previous Address:   Street/ No PO Box:    City:   

State:    Zip:  

All Members of Household & Drivers of Vehicles: 

1)    Name:    DOB:  SSN 
DL #    M/S    G/S    Age Lic   

Violations, Tickets, Accidents, Suspensions, Insurance Claims In The Last 5 Years (List dates, descriptions, amounts paid)   

2)    Name:  DOB:  SSN 
DL #  M/S  G/S  Age Lic 

Violations, Tickets, Accidents, Suspensions, Insurance Claims In The Last 5 Years (List dates, descriptions, amounts paid) 

3)    Name:  DOB:  SSN 
DL #  M/S  G/S  Age Lic 

Violations, Tickets, Accidents, Suspensions, Insurance Claims In The Last 5 Years (List dates, descriptions, amounts paid) 

4)    Name:  DOB:  SSN 
DL #  M/S  G/S  Age Lic 

Violations, Tickets, Accidents, Suspensions, Insurance Claims In The Last 5 Years (List dates, descriptions, amounts paid) 

Vehicle Information: 

1)   Year:    Make/Model/Sub Model (SL, SE, GL, GT)    

# Doors, Cyl, 4x4    VIN    # Air Bags, ABS, Alarm   

Use    Miles/Week    Days    Annual Miles    Op #     

Physical Damage    Garage or Carported    Vehicle Owner  

2)   Year:    Make/Model/Sub Model (SL, SE, GL, GT)    

# Doors, Cyl, 4x4    VIN  # Air Bags, ABS, Alarm   

Use    Miles/Week  Days    Annual Miles    Op #   

Physical Damage    Garage or Carported    Vehicle Owner  

3)   Year:    Make/Model/Sub Model (SL, SE, GL, GT)  

# Doors, Cyl, 4x4    VIN    # Air Bags, ABS, Alarm   

Use    Miles/Week    Days    Annual Miles    Op #     

Physical Damage    Garage or Carported    Vehicle Owner

4)   Year:  Make/Model/Sub Model (SL, SE, GL, GT)    

# Doors, Cyl, 4x4    VIN  # Air Bags, ABS, Alarm   

Use    Miles/Week    Days  Annual Miles    Op #   

Physical Damage    Garage or Carported    Vehicle Owner  

5)   Year:  Make/Model/Sub Model (SL, SE, GL, GT)    

# Doors, Cyl, 4x4    VIN    # Air Bags, ABS, Alarm 

Use    Miles/Week    Days    Annual Miles    Op #     

Physical Damage    Garage or Carported  Vehicle Owner  


Other: 
Six Full Months Prior Coverage Without Lapse? 
 
Current Carrier:   

Years/Months With Current Carrier:       License Ever Suspended or Ever Had a Major Violation (DWI, DUI, BAC):   

Own or Rent Home/Mobile/Condo:    Ever Convicted Of A Felony: 
 

Other Insurance With Mitchell:   

Boat Horsepower    Boat Max Speed    Cycle CC's   


Vehicle Coverages:
 

Liability Limits    Med Pay    UM   

UIM    Towing   

Rental Reimbursement    Comp Ded $    Coll Ded $   

Are The Above Limits The Insureds Current Limits Of Insurance?   

If Not Please List Insureds Current Liability Limits   

Will The Insured Need A Good Payment Plan or Is It Possible To Pay In Full & Get A Paid In Full Discount?    Permission To Run MVR:   

Permission To Run Credit Score:    Ever Filed Bankruptcy   

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