HOURS
Monday-Friday:
8:00am - 5:00pm
-----
Evenings & Weekends:
By appointment


Phone:      419.523.4500      
Toll Free:  800.686.4500      
----------                 
Fax:          419.523.0045      




Please complete and submit this
questionnaire so a proposal/quote
can be provided to you.

  

Auto and/or Homeowner
Insurance Questionnaire

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* indicates "required information"
* indicates "required information" when applicable
Personal Information:
  Name: *
  Address: *
  Zip Code : *
 
 
  Phone #: *
  Cell #:   
  Fax #:   
  Email Address: *
  Need By:   
  
  
  

Auto
  Current Company/Carrier: *
  Renewal Date:   
  
  
  

Coverages:
   Liability:   
   Medical Payments:   
   Under/Un-insured
         Motorist:		   
 
 
Comprehensive
Collision
Towing/Labor
Rental
 
1
2
3
4
  
  
  

Drivers:
  Name: *
  Birth Date: *
  Social Security #: *
  Sex: *
  Relationship: *
  Car Driven: *
  Use: *
  Miles to Work: *
  Good Student:
          (3.0 or better)		 *
  Car Pool: *
 
  Name: *
  Birth Date: *
  Social Security #: *
  Sex: *
  Relationship: *
  Car Driven: *
  Use: *
  Miles to Work: *
  Good Student:
          (3.0 or better)		 *
  Car Pool: *
 
  Name: *
  Birth Date: *
  Social Security #: *
  Sex: *
  Relationship: *
  Car Driven: *
  Use: *
  Miles to Work: *
  Good Student:
         (3.0 or better)		 *
  Car Pool: *
 
  Name: *
  Birth Date: *
  Social Security #: *
  Sex: *
  Relationship: *
  Car Driven: *
  Use: *
  Miles to Work: *
  Good Student:
         (3.0 or better)		 *
  Car Pool: *
 
  Name: *
  Birth Date: *
  Social Security #: *
  Sex: *
  Relationship: *
  Car Driven: *
  Use: *
  Miles to Work: *
  Good Student:
         (3.0 or better)		 *
  Car Pool: *
 
  Individual
         Occupations:		   
    
  Years Employed:   
    
  College:   
    
  
 
  

Vehicles:
              Vehicle #1  
    Year:   *
  Make:   *
  Model:   *
  V.I.N./Serial #:   *
       Vehicle #2  
  Year:   *
  Make:   *
  Model:   *
  V.I.N./Serial #:   *
       Vehicle #3  
  Year:   *
  Make:   *
  Model:   *
  V.I.N./Serial #:   *
       Vehicle #4  
  Year:   *
  Make:   *
  Model:   *
  V.I.N./Serial #:   *
  
  
  

Violations (in the past 5 years):
  Driver:   
  Date:   
  Violation Type:   
  At-Fault:   
  Not-At-Fault:   
 
  Driver:   
  Date:   
  Violation Type:   
  At-Fault:   
  Not-At-Fault:   
  
  
  
Description of any accident -- At-Fault or Not-At-Fault:
  
  
 
  

Homeowners
  Current Company/Carrier: *
  Renewal Date:   
  Dwelling Amount:   
  Liability:   
  Medical Payments:   
  Deductible:   
  Year Constructed:   
  Brick or Frame:   
  Total Sq. Ft.:   
  Basement/Finish:   
  Garage/Attached:   
  Outbuildings:   
  Miles to City:   
  Responding Fire Dept.:   
  Dogs/Breed:   
  Swimming Pool   
      Slide:   
      Diving Board:   
  Acres at Location:   
  Do you Farm?:   
     
  Trampoline:   
Scheduled Items          Needing Coverage
            (jewelry, ATV's, etc.):		   
 
 
  

LOSSES/CLAIMS (in last 5 years):
 
 
  

CREDITS:
  Smoke Alarms:   
  Dead Bolts:   
  Fire Extinguishers:   
  Security System:   
  Auto/Homeowner
         Discount:		   
 
 
 

MISC. INFO:

   


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