Mizuno Insurance Agency

Mizuno Insurance Agency
 
California Insurance License Number 0E83160

AUTOMOBILE INSURANCE QUESTIONNAIRE

Please provide the following contact information:
ALL QUESTIONS THAT ARE APPLICABLE MUST BE ANSWERED

  

Name
Address
City:
Zip Code:
Phone (optional):
E-mail Address :
Do you own a home?:  


Driver #1 Information

Name
Date of Birth (mm/dd/yy)
D.L.#
Marital Status  
Gender    
Date U.S. license first issued (mm/yy)
Date foreign country license issued (mm/yy)
Which country?
 Are you a F/T student?  
If YES, do you have a 3.0 GPA?  


Driver #2 Information

Name
Date of Birth (mm/dd/yy)
D.L.#
Marital Status  
Gender    
Date U.S. license first issued (mm/yy)
Date foreign country license issued (mm/yy)
Which country?
 Are you a F/T student?  
If YES, do you have a 3.0 GPA?  


Vehicle#1 Information

Vehicle Identification Number:
Primary Drivers name:
Usage:
1 way mileage to work/school:
Bus use average daily mileage:
Comp. Deductible:
Coll. Deductible:
Uninsured Motorist Property Damage $3500:


Vehicle#2 Information

Vehicle Identification Number:
Primary Drivers name:
Usage:
1 way mileage to work/school:
Bus use average daily mileage:
Comp. Deductible:
Coll. Deductible:
Uninsured Motorist Property Damage $3500:


Coverage
Please indicate your current coverage below

Bodily Injury:     
   
Uninsured Motorist Bodily Injury:    
    
Property Damage:    
Medical Payments:
Extended Transportation     
Towing Coverage  
Combined Single Limit Policy
Bodily Injury:    
Uninsured Motorist Bodily Injury:     


Remarks

 

   

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Date Time: 11-26-2020 03:08:11 PM