Personal Automobile Insurance Application

Step 1 of 9

INSURED INFORMATION

Name*

Full Name

Name of co-applicant:

Full Name

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone Number*

Business Phone Number*

Email*

DRIVER INFORMATION (Please complete for each driver you want to insure)

Driver Name*

Marital Status*

Gender*

Date of Birth*

Date Licensed*

Social Security Number*

Second Driver?

Yes

SECOND DRIVER INFORMATION (Please complete the info)

Driver Name*

Marital Status*

Gender*

Date of Birth*

Date Licensed*

Social Security Number*

Third Driver?

Yes

THIRD DRIVER INFORMATION (Please complete the info)

Driver Name*

Marital Status*

Gender*

Date of Birth*

Date Licensed*

Social Security Number*

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.)

Owner*

Date*

Type*

Second Driver*

Date*

Type*

Third 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*

Date*

BROKER*

TELEPHONE*

Comments

This field is for validation purposes and should be left unchanged.

Personal Automobile Insurance Application

INSURED INFORMATION

DRIVER INFORMATION (Please complete for each driver you want to insure)

SECOND DRIVER INFORMATION (Please complete the info)

THIRD DRIVER INFORMATION (Please complete the info)

VEHICLE INFORMATION (Please complete for each vehicle you want to insure)

Percentage of Use per Driver

SECOND VEHICLE INFORMATION (Please complete the info)

Percentage of Use per Driver

THIRD VEHICLE INFORMATION (Please complete the info)

Percentage of Use per Driver

CURRENT INSURANCE INFORMATION

DRIVING HISTORY - Please list ALL accidents and violations for ALL drivers in the last 36 months (At-Fault, Not-at-Fault, Moving Violations, etc.)

INFORMATION RELEASE FORM

WARRANTY