YOUR NAME:
YOUR ADDRESS:
CITY & STATE:
ZIP CODE:
HOME PHONE:
WORK PHONE:
E-MAIL ADDRESS:
LIENHOLDER on Auto (if any):
As part of our underwriting process for all applicants, to provide you with an accurate premium amount, we must ask you a series of questions. Your answers to some of these questions will be confirmed through consumer reports, which may include credit information. This information will be available to all of the business entities that make up the our Group of Insurance Companies. Do you wish to continue?
(Please write "YES" or "NO" below):
A. List all drivers in household:
1. NAME:
Date of Birth:
Social Security Number:
Marital Status (M, D, W, S):
2. NAME:
Date of Birth:
Social Security Number:
Marital Status (M, D, W, S):
3. NAME:
Date of Birth:
Social Security Number:
Marital Status (M, D, W, S):
4. NAME:
Date of Birth:
Social Security Number:
Marital Status (M, D, W, S):
B. List DRIVER'S LICENSE NUMBERS for all drivers named above:
Driver #1 above:
Driver #2 above:
Driver #3 above:
Driver #4 above:
C. List all DRIVERS named above with the VEHICLES they operate:
1. DRIVER'S NAME:
Vehicle Year & Make:
Model & Vehicle Identification #:
Distance to Work or School:
2. DRIVER'S NAME:
Vehicle Year & Make:
Model & Vehicle Identification #:
Distance to Work or School:
3. DRIVER'S NAME:
Vehicle Year & Make:
Model & Vehicle Identification #:
Distance to Work or School:
4. DRIVER'S NAME:
Vehicle Year & Make:
Model & Vehicle Identification #:
Distance to Work or School:
Defensive Driving Course? (Y/N):
Student GPA:
Business Use of Auto? (Y/N):
Renewal Date?:
Nearly finished! (Please continue on PAGE 2.)
PAGE 2
D. Tickets/Accidents in Past 3 Years:
1. DRIVER'S NAME:
Ticket Dates:
Dates of Major Citations (past 5 yrs):
Dates of At-Fault Accidents:
Dates of Not-At-Fault Accidents:
2. DRIVER'S NAME:
Ticket Dates:
Dates of Major Citations (past 5 yrs):
Dates of At-Fault Accidents:
Dates of Not-At-Fault Accidents:
3. DRIVER'S NAME:
Ticket Dates:
Dates of Major Citations (past 5 yrs):
Dates of At-Fault Accidents:
Dates of Not-At-Fault Accidents:
4. DRIVER'S NAME:
Ticket Dates:
Dates of Major Citations (past 5 yrs):
Dates of At-Fault Accidents:
Dates of Not-At-Fault Accidents:
E. Desired Insurance Coverage:
VEHICLE #1
Liability Limits:
Uninsured Motorist Limit:
Medical:
Comprehensive Deductible:
Collision Deductible:
VEHICLE #2
Liability Limits:
Uninsured Motorist Limit:
Medical:
Comprehensive Deductible:
Collision Deductible:
VEHICLE #3
Liability Limits:
Uninsured Motorist Limit:
Medical:
Comprehensive Deductible:
Collision Deductible:
VEHICLE #4
Liability Limits:
Uninsured Motorist Limit:
Medical:
Comprehensive Deductible:
Collision Deductible:
F. Additional Questions:
Any stereo equipment in car other than factory-installed?
If yes, is its value?
Any campers or trailers?
If yes, is the value?
Has any member of household ever had their license cancelled, suspended, or revoked?
Driver:
Date:
Current Insurance Company (if any):
Has any company ever canceled or declined to renew your insurance coverage?
If yes, company name and date:
You may include any additional information here. Please feel free to include your comments.
THE ARVISOM INSTITUTE
FARMERS AGENT: Marvin C. Sterling
msterling@arvisom.com
2200 Shadowlake Drive
Farmers Insurance Group
Oklahoma City, OK 73189-2165