Mizuno Insurance Agency

Mizuno Insurance Agency
 
California Insurance License Number 0E83160

AUTOMOBILE INSURANCE QUESTIONNAIRE (for 3rd and 4th Driver / Car )

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

 

Your Name


Driver #3 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 #4 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#3 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#4 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:

 

 


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Date Time: 11-20-2018 08:21:21 PM