Fillable Printable Personal Automobile Insurance Application
Fillable Printable Personal Automobile Insurance Application
Personal Automobile Insurance Application
Personal Automobile Insurance Application
Please fax completed application along with the declarations page(s) of your current policy
INSURED INFORMATION
Name:
Name of co-applicant:
Address:
City:
County: State: Zip: Rent/Own:
Home Phone Number:
Business Phone Number:
Email Address:
DRIVER INFORMATION (Please complete for each driver you want to insure)
Driver 1 Driver 2 Driver 3
Name: Name: Name:
Marital Status: Marital Status: Marital Status:
Gender: Date of Birth: Gender: Date of Birth: Gender: Date of Birth:
Date Licensed: Date Licensed: Date Licensed:
Driver’s License Number & State: Driver’s License Number & State: Driver’s License Number & State:
Social Security Number: Social Security Number: Social Security Number:
VEHICLE INFORMATION (Please complete for each vehicle you want to insure)
Vehicle 1 Vehicle 2 Vehicle 3
Vehicle ID Number (VIN): Vehicle ID Number (VIN): Vehicle ID Number (VIN):
Year/Make/Model: Year/Make/Model: Year/Make/Model:
Annual Mileage: Annual Mileage: Annual Mileage:
Usage:
Business Pleasure
Carpool
Other
Usage:
Business Pleasure
Carpool
Other
Usage:
Business Pleasure
Carpool
Other
Anti-lock
Brakes:
None 4 Wheel Standard
4 Wheel After market
Anti-lock
Brakes:
None 4 Wheel Standard
4 Wheel After market
Anti-lock
Brakes:
None 4 Wheel Standard
4 Wheel After market
Air Bag:
None
Driver
Driver & Passenger
Air Bag:
None
Driver
Driver & Passenger
Air Bag:
None
Driver
Driver & Passenger
Anti-theft:
None Alarm Only
Vehicle Retrieval System
VIN Etching
Active Disabling Device
Passive Disabling Device
Anti-theft:
None Alarm Only
Vehicle Retrieval System
VIN Etching
Active Disabling Device
Passive Disabling Device
Anti-theft:
None Alarm Only
Vehicle Retrieval System
VIN Etching
Active Disabling Device
Passive Disabling Device
Percentage of Use per Driver: Driver 1 _______
Driver 2 _______ Driver 3 _______
Percentage of Use per Driver: Driver 1 _______
Driver 2 _______ Driver 3 _______
Percentage of Use per Driver: Driver 1 _______
Driver 2 _______ Driver 3 _______
Vehicle Garaged Mailing Address: Yes No Vehicle Garaged Mailing Address: Yes No Vehicle Garaged Mailing Address: Yes No
CURRENT INSURANCE INFORMATION
Carrier: Years with Carrier:
Bodily Injury Limits: Property Damage Limit:
Collision Deductible: Comprehensive Deductible:
DRIVING HISTORY Please list ALL accidents and violations for ALL drivers in the last 36 months (At-Fault, Not-at-Fault, Moving Violations, etc.)
Driver: Date: Type:
Driver: Date: Type:
Driver: Date: Type:
INFORMATION RELEASE FORM
As part of the application process in obtaining the insurance coverage you are requesting from licensed insurance
carriers of Allen Financial Insurance Group, Inc. and/or it’s licensed carriers may order one or more consumer reports.
A consumer report may contain information on credit history, medical conditions, driving records, criminal activity and
hazardous sports, among other things.
Under the Fair Credit Reporting Act, Allen Financial Insurance Group, Inc. and/or it’s licensed carriers may review
consumer reports to evaluate anyone who applies for this insurance. In the event that coverage is denied to you based
wholly or partly on information in a consumer report you will be notified of this fact and given the name and address of the
consumer reporting agency making the report.
It is understood and agreed that the completion of this application shall not be binding either to the proposed insured or
to the Company until accepted by the Company or Companies but that the information contained herein shall be the
basis of the contract should a policy be issued.
WARRANTY
I/We understand and agree that any misstatement of warranty or fact on this application shall be considered a violation of
coverage afforded under any policy issued on the basis of this application. I/We understand and agree that this
application shall form part of any policy issued.
APPLICANT
Signature Date
BROKER TELEPHONE ( )
