Walterry Insurance: Auto Insurance Application Customer Information Contact Name (First Person) Second Person Address City, State, Zip Phone (Home) (Work) (Fax) (Email Address) "required" Occupation (A) How long? (years/months) Occupation (B) How long? (years/months) Age (A) Age (B) Children (Ages) Male Female Residence select one Owned Home Owned Condominium Rented Home/Condo Apartment Live With Relative/Friend How do you wish to be contacted? select one Phone Fax US Mail E-Mail Automobile Information Current Insurance Company How long? Policy Renewal Date Vehicle # Year Make Model Doors(#) Serial Number (If Known) Primary Driver (Name) How is vehicle driven? Pleasure Use Only Commute Miles One Way Car Pool Miles One Way Used In Business If you have additional vehicles you would like to include in your application please continue to fill out information below. If not, click here . Vehicle #2 Policy Renewal Date Vehicle # Year Make Model Doors(#) Serial Number (If Known) Primary Driver (Name) How is vehicle driven? Pleasure Use Only Commute Miles One Way Car Pool Miles One Way Used In Business If you have additional vehicles you would like to include in your application please continue to fill out information below. If not, click here . Vehicle #3 Policy Renewal Date Vehicle # Year Make Model Doors(#) Serial Number (If Known) Primary Driver (Name) How is vehicle driven? Pleasure Use Only Commute Miles One Way Car Pool Miles One Way Used In Business Coverages Liability Coverage 20,000/40,000/10,000 25,000/50,000/25,000 50,000/100,000/50,000 100,000/300,000/100,000 250,000/500,000/250,000 Personal Injury Protection$2,500(choose one) Yes No Medical Payments None 1,000 2,000 5,000 Comprehensive Coverage Deductible None 50 100 250 500 Collision Coverage Deductible 100 250 500 1,000 Towing Coverage None 25 50 75 Rental Reimbursement Yes No In the last three years, have any of the following situations occurred? Please provide details of any "yes" responses in the Details section. Had your Auto Insurance canceled? Yes No Been involved in an accident where you were not at fault? Yes No Been involved in an accident where you were at fault? Yes No Been uninsured for any period of time? Yes No Received a traffic citation for any violation other than parking? Yes No Had your vehicle hit while parked, vandalized or stolen? Yes No Details Copyright © 2005 Walterry Insurance Brokers [ Forms ] [ Contact Us ] [ Privacy Policy ] [ Home ]