Personal Auto Insurance Renewal Questionnaire

Please review your renewal carefully!  The following questions are designed to assist both of us in this review.

( * indicates required field)

GENERAL INFORMATION:
*Name:
*Address:
*City:
*State:
*Zip Code:
*Policy Number
*E-mail address:
*Home Phone Number:
*Daytime Phone Number:
Is the named insured and address listed on the policy correct? Yes No
 
DRIVER INFORMATION:
Is anyone in your household of driving age and NOT listed on your policy? Yes No
 
If you answered “yes”, please provide the following information:
Driver 1: Name:
  Sex: Male Female Marital Status: Single Married
Relationship to Insured:
Date of Birth: Mo.   Day     Year
Date First Licensed: Mo.    Year Driver's License State:
Driver's License Number: Social Sec. Number:
   
Driver 2: Name:
  Sex: Male Female Marital Status: Single Married
Relationship to Insured:
Date of Birth: Mo.   Day     Year
Date First Licensed: Mo.    Year Driver's License State:
Driver's License Number: Social Sec. Number:
   
VEHICLE INFORMATION :
Do you own any vehicles other than those listed on your policy? Yes No
 
If you answered “yes”, please provide the following information:
New
Vehicle 1: 		Purchase Date: Mo.    Year Cost:
Make: Model:
Year: Anti-lock Brakes: Yes No
Vehicle Identification Number: Alarm: Yes No
Comprehensive Deductible: N/A $100 $250 $500 $1000
Collision Deductible: N/A $100 $250 $500 $1000
Rental Reimbursement: 20/$600 30/$900 Towing: Yes No
 
New
Vehicle 2: 		Purchase Date: Mo.    Year Cost:
Make: Model:
Year: Anti-lock Brakes: Yes No
Vehicle Identification Number: Alarm: Yes No
Comprehensive Deductible: N/A $100 $250 $500 $1000
Collision Deductible: N/A $100 $250 $500 $1000
Rental Reimbursement: 20/$600 30/$900 Towing: Yes No
 
Please provide the following information for ALL OWNED VEHICLES:
 
Vehicle 1: Primary Driver:
  Make: Model:
Year: Vehicle Usage: Pleasure Commute
If commuting,
number of miles one way: 		If commuting, number of days per week:
Annual Mileage: (average is 10-15,000)
       
Vehicle 2: Primary Driver:
  Make: Model:
Year: Vehicle Usage: Pleasure Commute
If commuting,
number of miles one way: 		If commuting, number of days per week:
Annual Mileage: (average is 10-15,000)
 
Vehicle 3: Primary Driver:
  Make: Model:
Year: Vehicle Usage: Pleasure Commute
If commuting,
number of miles one way: 		If commuting, number of days per week:
Annual Mileage: (average is 10-15,000)
       
Vehicle 4: Primary Driver:
  Make: Model:
Year: Vehicle Usage: Pleasure Commute
If commuting,
number of miles one way: 		If commuting, number of days per week:
Annual Mileage: (average is 10-15,000)
   
COVERAGES:
After reviewing ALL of your policy, do you have adequate coverage? Yes No
 
If you answered “no” to question 4, do you wish to increase or add any of the following:
Bodily Injury: $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Property Damage: $50,000 $100,000
Medical Expense: $1,000 $2,000 $5,000 $10,000
Loss of Income: Yes No
Uninsured Motorist Bodily Injury: $50,000/$100,000 $100,000/$300,000 $250,000/$500,000
Uninsured Motorist
Property Damage:		 $50,000 $100,000
Vehicle 1:

  
Comprehensive Deductible: N/A $100 $250 $500 $1000
Collision Deductible: N/A $100 $250 $500 $1000
Rental Reimbursement: 20/$600 30/$900 Towing: Yes No
Vehicle 2:

  
Comprehensive Deductible: N/A $100 $250 $500 $1000
Collision Deductible: N/A $100 $250 $500 $1000
Rental Reimbursement: 20/$600 30/$900 Towing: Yes No
Vehicle 3:

  
Comprehensive Deductible: N/A $100 $250 $500 $1000
Collision Deductible: N/A $100 $250 $500 $1000
Rental Reimbursement: 20/$600 30/$900 Towing: Yes No
Vehicle 4:

  
Comprehensive Deductible: N/A $100 $250 $500 $1000
Collision Deductible: N/A $100 $250 $500 $1000
Rental Reimbursement: 20/$600 30/$900 Towing: Yes No
   
Are there any other coverages you want to discuss such as:
Life
Health
Homeowners
Personal Umbrella
   
Additional Coverages needed
and/or additional comments:

I understand that NO changes to my policy or coverage are bound by submitting this online Renewal Request.
This Change request will be considered bound ONLY upon confirmation from my LIA agent.

I have read and agree with the above.
(Box must be checked before request is sent)
NOTE: This is to become part of your permanent insurance record with Lewis Insurance Associates
and will be shared with the company you are insured with.


   

 

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