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| Insured Information |
| Insured First Name Last Name |
| Date of Birth (mm/dd/yy) | | | |
| Address |
| City State Zip |
| Contact Phone # Email Address |
| Preferred Method of Contact Phone Email | | | |
| Best Time to Contact You Day (9-5) Evening (after 6) | | | |
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| Current Insurance |
| Do you presently have Auto Insurance? | Yes No | | | |
| Company Name | | | |
| How long have you been with this company? | | | |
| Renewal Date (mm/dd/yy) | | | | |
| Annual Premium | | | | |
| Have you been cancelled or non-renewed in the past 3 years? | Yes No | | | |
| Do you presently have Homeowner/Property Insurance? | Yes No | | | |
| Company Name | | | |
| Renewal Date (mm/dd/yy) | | | | |
| How long have you been with this company? | | | |
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Coverages
Please select the amount of coverage for each of the categories below. |
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| Bodily Injury Liability | | | |
| Property Damage Liability | | | |
| Medical Payments | | | |
| Uninsured Motorist Liability | | | |
| Underinsured Motorist Liability | | | |
| Comprehensive Deductible | | | |
| Collision Deductible | | | |
| Do you want rental reimbursement? | | | |
| Do you want coverage for towing and labor? | | | |
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Licensed Drivers
Please provide the following information for all licensed drivers residing in your home. |
| Primary Driver | | Driver #2 | |
| Name on License | | | | |
| License State | | | | |
| License Number | | | | |
| Date of Birth | | | | |
| Year First Licensed | | | | |
| Gender | | | | |
| Marital Status | | | | |
| | Relation to Primary Driver | | |
| Occupation | | | | |
| Good Student | Yes No | | Yes No | |
Advanced Driver Training
(In Control or Skid School) | Yes No | | Yes No | |
| Please use the space to the right to list all tickets received or accidents that this driver has been inovlved in within the last 5 years. | | |
| Driver #3 | | Driver #4 | |
| Name on License | | | | |
| License State | | | | |
| License Number | | | | |
| Date of Birth | | | | |
| Year First Licensed | | | | |
| Gender | | | | |
| Marital Status | | | | |
| Relation to Primary Driver | | | | |
| Occupation | | | | |
| Good Student | Yes No | | Yes No | |
Advanced Driver Training
(In Control or Skid School) | Yes No | | Yes No | |
| Please use the space to the right to list all tickets received or accidents that this driver has been inovlved in within the last 5 years. | | |
| If there are other residents in your household that are licensed to drive, please list them below. | |
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| Driver #5 | | | | |
| Driver #6 | | | | |
| Driver #7 | | | | |
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| Vehicle Information |
| Vehicle #1 | Vehicle #2 | Vehicle #3 | |
| Year | | | | |
| Make | | | | |
| Model | | | | |
| Vehicle Identification Number (VIN) | | | | |
| Plate Number | | | | |
| State | | | | |
| Annual Mileage | | | | |
| # of Doors | | | | |
| Describe alarm system, if any. | | | | |
| Air Bags | | | | |
| Auto Seatbelts | | | | |
| Do you use this vehicle for business? | | | | |
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| Other Information |
| Do you use public transportation and have 12 month passes? | |
| Do you belong to AAA? | Member # |
| Are you interested in electronic payment? | |
| How did your hear about Atlantic Advisers? | | |
| Please use the space provided for any comments or questions that you may have. |
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Keep this box checked to receive the latest information on insurance products and services. |
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