AUTOMOBILE INFORMATION SHEET
Please FAX completed form to Dave at (201) 652-0721
Name: __________________________________ Today’s Date: ____________________
Mailing Address: _____________________________________________________________
Telephone Number(s): HOME ___________ CELL ____________ WORK ____________
Please complete the following on ALL licensed drivers in the household, including drivers who may have their own insurance:
Name Date of Birth Soc. Sec. # Driver’s License # State M/F Year Marital
Licensed Status
Vehicle Information:
Vehicle Year Make Model VIN # Stock, Modified or Exotic Type Value
#1 ___________________________________________________________________________
#2 ___________________________________________________________________________
#3 ___________________________________________________________________________
#4 ___________________________________________________________________________
Type of Protective Device Where Parked Comprehensive Collision
On/Off Street Deductible Deductible
#1 ___________________________________________________________________________
#2 ___________________________________________________________________________
#3 ___________________________________________________________________________
#4 ___________________________________________________________________________
Primary Auto Insurance Company Name & Expiration Date: _____________________________
List below, ANY CLAIMS or ACCIDENTS, in the last 5 years, for ANY driver on this policy.
How did you hear of our Agency? __________________________________________________
Antique vehicle(s) can be used mainly in exhibitions, club activities, parades and other functions of public interest but cannot be used primarily for the transportation of passengers or goods.
WE WILL NEED TO ORDER AN INSURANCE SCORE FOR QUOTING. PLEASE INITIAL WHERE INDICATED FOR PERMISSION TO ORDER SAID DOCUMENT.
X _________