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

RequiredFieldValidator

Name

Address

City:

Zip Code:

Phone (optional):

E-mail Address :

Do you own a home?: Yes No

Driver #1 Information

Name

Date of Birth (mm/dd/yy)

D.L.#

Marital Status Single Married

Gender Male    Female

Date U.S. license first issued (mm/yy)

Date foreign country license issued (mm/yy)

Which country?

Are you a F/T student? Yes No

If YES, do you have a 3.0 GPA? Yes No

Driver #2 Information

Name

Date of Birth (mm/dd/yy)

D.L.#

Marital Status Single Married

Gender Male    Female

Date U.S. license first issued (mm/yy)

Date foreign country license issued (mm/yy)

Which country?

Are you a F/T student? Yes No

If YES, do you have a 3.0 GPA? Yes No

Vehicle#1 Information

Vehicle Identification Number:

Primary Drivers name:

Usage: Pleasure Work/School Business

1 way mileage to work/school:

Bus use average daily mileage:

Comp. Deductible:

Coll. Deductible:

Uninsured Motorist Property Damage $3500: Yes No

Vehicle#2 Information

Vehicle Identification Number:

Primary Drivers name:

Usage: Pleasure Work/School Business

1 way mileage to work/school:

Bus use average daily mileage:

Comp. Deductible:

Coll. Deductible:

Uninsured Motorist Property Damage $3500: Yes No

Coverage
Please indicate your current coverage below

Bodily Injury: $15,000/30,000    $25,000/50,000
$50,000/100,000 $100,000/300,000
$250,000/500,000 N/A

Uninsured Motorist Bodily Injury: $15,000/30,000    $25,000/50,000
$30,000/60,000 $50,000/100,000
$100,000/300,000$250,000/500,000 N/A

Property Damage: $5,000 $10,000 $25,000
$50,000 $100,000 N/A

Medical Payments: $500 $1,000 $2,000 $5,000 $10,000 N/A

Extended Transportation 15/450 20/600 30/900 N/A

Towing Coverage $35 $50 N/A

Combined Single Limit Policy

Bodily Injury: $30,000 $50,000 $100,000 $250,000
$300,000 $500,000 N/A

Uninsured Motorist Bodily Injury: $30,000   $50,000 $100,000 $250,000
$300,000 $500,000 N/A

Remarks

*Name*
*Address*
*City:*
*Zip Code:*
*Phone (optional):*
E-mail Address :
Do you own a home?:	Yes No

Driver #1 Information
*Name*
Date of Birth	(mm/dd/yy)
D.L.#
Marital Status	Single Married
Gender	Male Female
Date U.S. license first issued	(mm/yy)
Date foreign country license issued	(mm/yy)
Which country?
Are you a F/T student?	Yes No
If YES, do you have a 3.0 GPA?	Yes No

Driver #2 Information
*Name*
Date of Birth	(mm/dd/yy)
D.L.#
Marital Status	Single Married
Gender	Male Female
Date U.S. license first issued	(mm/yy)
Date foreign country license issued	(mm/yy)
Which country?
Are you a F/T student?	Yes No
If YES, do you have a 3.0 GPA?	Yes No

Vehicle#1 Information
Vehicle Identification Number:
Primary Drivers name:
Usage:	Pleasure Work/School Business
1 way mileage to work/school:
Bus use average daily mileage:
Comp. Deductible:
Coll. Deductible:
Uninsured Motorist Property Damage $3500:	Yes No

Vehicle#2 Information
Vehicle Identification Number:
Primary Drivers name:
Usage:	Pleasure Work/School Business
1 way mileage to work/school:
Bus use average daily mileage:
Comp. Deductible:
Coll. Deductible:
Uninsured Motorist Property Damage $3500:	Yes No

Coverage Please indicate your current coverage below
Bodily Injury:	$15,000/30,000 $25,000/50,000 $50,000/100,000 $100,000/300,000 $250,000/500,000 N/A
Uninsured Motorist Bodily Injury:	$15,000/30,000 $25,000/50,000 $30,000/60,000 $50,000/100,000 $100,000/300,000$250,000/500,000 N/A
Property Damage:	$5,000 $10,000 $25,000 $50,000 $100,000 N/A
Medical Payments:	$500 $1,000 $2,000 $5,000 $10,000 N/A
Extended Transportation	15/450 20/600 30/900 N/A
Towing Coverage	$35 $50 N/A
Combined Single Limit Policy
Bodily Injury:	$30,000 $50,000 $100,000 $250,000 $300,000 $500,000 N/A
Uninsured Motorist Bodily Injury:	$30,000 $50,000 $100,000 $250,000 $300,000 $500,000 N/A

Designed by SAT Computer Copyright (c) 2007,2020 Mizuno Insurance Agency. All rights reserved. Date Time: 01-11-2026 09:18:47 AM

Designed by SAT Computer
Copyright (c) 2007,2020 Mizuno Insurance Agency. All rights reserved.
Date Time: 01-11-2026 09:18:47 AM