Auto Questionnaire - Northern Kentucky Insurance

Auto Questionnaire

Referred By:

Date:

New or Renewal

Named Insured(s):

Current Insurance Carrier:

How Long:

Exp. Date:

Billing Preference:

Billing Type

Would you like Electronic Docs?

Driver Information

Every driver in the household must be listed regardless if they have their own insurance.

Driver Name (1):

Relation (1):

Date of Birth (1):

Drivers License # (1):

State (1):

Date Licensed (1):

Driver Included or Excluded (1)?

Occupation (1):

Education Level (1):

Relation (1):

Good Student (1):

Safety Course (1):

Driver 2

Driver Name (2):

Relation (2):

Date of Birth (2):

Drivers License # (2):

State (2):

Date Licensed (2):

Driver Included or Excluded (2)?

Occupation (2):

Education Level (2):

Relation (2):

Good Student (2):

Safety Course (2):

Driver 3

Driver Name (3):

Relation (3):

Date of Birth (3):

Drivers License # (3):

State (3):

Date Licensed (3):

Driver Included or Excluded (3)?

Occupation (3):

Education Level (3):

Relation (3):

Good Student (3):

Safety Course (3):

Driver 4

Driver Name (4):

Relation (4):

Date of Birth (4):

Drivers License # (4):

State (4):

Date Licensed (4):

Driver Included or Excluded (4)?

Occupation (4):

Education Level (4):

Relation (4):

Good Student (4):

Safety Course (4):

Driver 5

Driver Name (5):

Relation (5):

Date of Birth (5):

Drivers License # (5):

State (5):

Date Licensed (5):

Driver Included or Excluded (5)?

Occupation (5):

Education Level (5):

Relation (5):

Good Student (5):

Safety Course (5):

Vehicle Information

Vehicle # (1):

Year (1):

Make (1):

Model (1):

Operator (1):

Use (1):

Miles Driven to Work (1):

Miles Driven Annually (1)

Titled To (1):

Purchase Date (1):

Value of Custom/Aftermarket Parts (1):

Comprehensive Deductible (1):

Collision Deductible (1):

Do you need GAP coverage? (1)

Vehicle 2

Vehicle # (2):

Year (2):

Make (2):

Model (2):

Operator (2):

Use (2):

Miles Driven to Work (2):

Miles Driven Annually (2)

Titled To (2):

Purchase Date (2):

Value of Custom/Aftermarket Parts (2):

Comprehensive Deductible (2):

Collision Deductible (2):

Do you need GAP coverage? (2)

Vehicle 3

Vehicle # (3):

Year (3):

Make (3):

Model (3):

Operator (3):

Use (3):

Miles Driven to Work (3):

Miles Driven Annually (3)

Titled To (3):

Purchase Date (3):

Value of Custom/Aftermarket Parts (3):

Comprehensive Deductible (3):

Collision Deductible (3):

Do you need GAP coverage? (3)

Vehicle 4

Vehicle # (4):

Year (4):

Make (4):

Model (4):

Operator (4):

Use (4):

Miles Driven to Work (4):

Miles Driven Annually (4):

Titled To (4):

Purchase Date (4):

Value of Custom/Aftermarket Parts (4):

Comprehensive Deductible (4):

Collision Deductible (4):

Do you need GAP coverage? (4)

Vehicle 5

Vehicle # (5):

Year (5):

Make (5):

Model (5):

Operator (5):

Use (5):

Miles Driven to Work (5):

Miles Driven Annually (5):

Titled To (4):

Purchase Date (5):

Value of Custom/Aftermarket Parts (5):

Comprehensive Deductible (5):

Collision Deductible (5):

Do you need GAP coverage? (5)

Accidents / Violations

Any accidents or violations in the past 5 years?

Date of Incident (1):

Loss or Violation (1):

Amount of Loss (1):

Driver (1):

Incident 2

Date of Incident (2):

Loss or Violation (2):

Amount of Loss (2):

Driver (2):

Incident 3

Date of Incident (3):

Loss or Violation (3):

Amount of Loss (3):

Driver (3):

Incident 4

Date of Incident (4):

Loss or Violation (4):

Amount of Loss (4):

Driver (4):

Underwriting Questions

Explain any vehicle used for business purposes?

Any vehicle used for delivery or livery services? (i.e. Uber, Lyft, Grub Hub, etc...)

Has any drivers license been revoked or suspended in the past 5 years?

Does any driver have a physical or medical impairment?

Coverages

Are you interested in Telematics?

Liability

Uninsured:

Under Insured:

PIP:

UM Property Damage:

Additional PIP:

Optional Coverages

Towing Roadside Coverage?

Rental Car Coverage?

New Vehicle Replacement Coverage?

OEM Replacement Coverage?

Accident Forgiveness Coverage?

Minor Violation Forgiveness Coverage?

Decreasing Deductible Coverage?

Limited Ride Sharing Coverage?

Lienholder

Vehicle (1):

Lienholder Name (1):

Address (1):

Loan # (1):

Lein 2

Vehicle (2):

Lienholder Name (2):

Address (2):

Loan # (2):

Lein 3

Vehicle (3):

Lienholder Name (3):

Address (3):

Loan # (3):

Lein 3

Vehicle (4):

Lienholder Name (4):

Address (4):

Loan # (4):

Final Remarks (Need Quote for Life, Health, Business?)

Attach Policy Dec Pages, Personal Article Appraisals, & any other useful information