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	Single  Married
Gender	Male    Female
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?	Yes  No	Yes  No	Yes  No
Major violations past 10 years?	Yes  No
DMV filing required	Yes  No
Are you a F/T student?	Yes  No
If YES, do you have a 3.0 GPA?	Yes  No

Driver #4 Information
Name
Date of Birth	(mm/dd/yy)
D.L.#
Marital Status	Single  Married
Gender	Male    Female
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?	Yes  No	Yes  No	Yes  No
Major violations past 10 years?	Yes  No
DMV filing required	Yes  No
Are you a F/T student?	Yes  No
If YES, do you have a 3.0 GPA?	Yes  No

Vehicle#3 Information
Year:
Make:
Model:
Vehicle Identification Number:
Garaging Zip Code:
Primary Drivers name:
Usage:	Pleasure Commute School Business
1 way mileage to work/school:
Bus use average daily mileage:
Comp. Deductible:
Coll. Deductible:
Waiver of Coll. Deductible:	Yes No
Uninsured Motorist Property Damage $3500:	Yes No

Vehicle#4 Information
Year:
Make:
Model:
Vehicle Identification Number:
Garaging Zip Code:
Primary Drivers name:
Usage:	Pleasure Commute School Business
1 way mileage to work/school:
Bus use average daily mileage:
Comp. Deductible:
Coll. Deductible:
Waiver of Coll. Deductible:	Yes No
Uninsured Motorist Property Damage $3500:	Yes No