To help us
supply you with the most accurate quote possible, please
answer as many questions as you can with the most accurate
information available to you.
Information submitted will
be held confidential and will be used for quote purposes
only.
Submission of application information in no way obligates
you to purchase any product or insurance, nor does it
represent any agreement to provide coverage under any
insurance policy.
PERSONAL
INFORMATION
Your name:
First:
Last:
E-Mail
address:
Phone
numbers:
Daytime:
Evening:
Fax:
How
would you prefer to be contacted
regarding your quote?
Phone
Fax
Mail
E-mail
If
you would prefer to be contacted by phone,
please let us know the best time to call.
Address:
City:
State:
Zip
code:
Do
you currently own your home, or rent?
Own
Rent
Driver's
license number:
Social
security number:
How Were You Referred To Copley Insurance?
DRIVER
INFORMATION
Name:
Relationship
to applicant:
Sex:
Marital
status:
Driver's
age:
Which
vehicle does he/she drive?
Percent
use:
Driver
#1
Male
Female
Married
Single
Driver
#2
Male
Female
Married
Single
Driver
#3
Male
Female
Married
Single
Driver
#4
Male
Female
Married
Single
DRIVER
HISTORY
Currently
insured with (company name not agency):
Have
you or any other driver in your household:
Had
a ticket in the last 3 years?
Had
a license suspended or revoked in the last 6 years?
Had
a financial responsibility filing in the last 6 years?
Made
any claims in the last 5 years?
Yes
No
Yes
No
Yes
No
Yes
No
If
you answered yes to any of the above questions, please
explain:
VEHICLE
#1 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:
Annual mileage:
Is the vehicle driven to
school or work?
If
driven to school or work, how many weeks per month?
If driven to school or work,
how many miles one way?
Yes
No
Days
Weeks
Miles
Is
the vehicle in any way modified or customized?
Is
there any existing damage to the vehicle?
Yes
No
Yes
No
If vehicle is kept at an
address other than that listed above, please indicate
below:
Address:
City:
State:
Zip:
VEHICLE
#2 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:
Annual mileage:
Is the vehicle driven to
school or work?
If
driven to school or work, how many weeks per month?
If driven to school or work,
how many miles one way?
Yes
No
Days
Weeks
Miles
Is
the vehicle in any way modified or customized?
Is
there any existing damage to the vehicle?
Yes
No
Yes
No
If vehicle is kept at an
address other than that listed above, please indicate
below:
Address:
City:
State:
Zip:
VEHICLE
#3 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:
Annual mileage:
Is the vehicle driven to
school or work?
If
driven to school or work, how many weeks per month?
If driven to school or work,
how many miles one way?
Yes
No
Days
Weeks
Miles
Is
the vehicle in any way modified or customized?
Is
there any existing damage to the vehicle?
Yes
No
Yes
No
If vehicle is kept at an
address other than that listed above, please indicate
below:
Address:
City:
State:
Zip:
VEHICLE
#4 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
Primary driver:
Annual mileage:
Is the vehicle driven to
school or work?
If
driven to school or work, how many weeks per month?
If driven to school or work,
how many miles one way?
Yes
No
Days
Weeks
Miles
Is
the vehicle in any way modified or customized?
Is
there any existing damage to the vehicle?
Yes
No
Yes
No
If vehicle is kept at an
address other than that listed above, please indicate
below:
Address:
City:
State:
Zip:
COVERAGE
OPTIONS
Bodily
injury liability:
Property
damage liability:
Underinsured
motorist-bodily injury:
Underinsured
motorist-property damage:
Medical-personal
injury protection:
Accidental
death:
COVERAGE
DEDUCTIBLES
Comprehensive
deductible:
Collision
deductible:
Towing
coverage
deductible:
Vehicle
#1
Vehicle
#2
Vehicle
#3
Vehicle
#4
QUESTIONS,
COMMENTS OR ADDITIONAL AUTOMOBILE INFORMATION?
