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:
Primary Phone #:
E-mail Address :
How long at above address?: years
Do you own a home?:  

If less than 1 year, previous address.

Address
City:
Zip Code:
How many drivers in the household?:
How many vehicles in the household?:
Please list current insurance company:


Driver #1 Information

Name
Date of Birth (mm/dd/yy)
D.L.#
Marital Status  
Gender    
Occupation
Date CA license first issued (mm/dd/yy)
How many years
Foreign driving experience
years
How many years
other state driving experience
years

Ticket or Accidents past 3 years

 
Date of violation
(mm/dd/yy)
Type of violation
Date of accident fault / non fault
(mm/dd/yy)
Was there any bodily injury?      
Major violations past 10 years?  
DMV filing required  
 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    
Occupation
Date CA license first issued (mm/dd/yy)
How many years
Foreign driving experience
years
How many years
other state driving experience
years

Ticket or Accidents past 3 years

 
Date of violation
(mm/dd/yy)
Type of violation
Date of accident fault / non fault
(mm/dd/yy)
 
Was there any bodily injury?      
Major violations past 10 years?  
DMV filing required  
 Are you a F/T student?  
If YES, do you have a 3.0 GPA?  


Vehicle#1 Information

Year:
Make:
Model:
Vehicle Identification Number:
Garaging Zip Code:
Primary Drivers name:
Usage:
1 way mileage to work/school:
Bus use average daily mileage:
Comp. Deductible:
Coll. Deductible:
Waiver of Coll. Deductible:
Uninsured Motorist Property Damage $3500:


Vehicle#2 Information

Year:
Make:
Model:
Vehicle Identification Number:
Garaging Zip Code:
Primary Drivers name:
Usage:
1 way mileage to work/school:
Bus use average daily mileage:
Comp. Deductible:
Coll. Deductible:
Waiver of 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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Copyright (c) 2007 Mizuno Insurance Agency. All rights reserved.
Date Time: 10-20-2018 08:18:12 PM