Auto Insurance Questionnaire Residents Please provide the following information for EACH RESIDENT of your household: (If the resident is not licensed please answer where applicable) Full Name (required) Date of Birth Driver's License # Social Security # Occupation Highest Level of Education Completed Marital Status Accidents, tickets, claims or violations in the last 5 YEARS If the resident has his/her own vehicle and carries his/her own insurance, please indicate that here Vehicles Please provide the following information for EACH VEHICLE in your household: Vehicle Year Vehicle Make Vehicle Model VIN# Primary Driver Usage Annual Mileage Existing Damage Titleholder Current Insurance Information Company # of years with this company Are you being canceled? YesNo If yes, for what reason? Policy Effective Dates Coverages ---Bodily InjuryProperty DamageMedicalUninsured/Underinsured Motorist BIUninsured Motorist Property DamageComprehensive DeductibleCollision DeductibleRoad Service/TowingRental ReimbursementOther If Other: Other Information Address (required) Phone Number (required) Email or Other Contact (required) Are you a: ---HomeownerRenterMedicalOther Please explain if other: Are there any coverage options you would like to discuss in detail? YesNo If yes, Additional Drivers Additional Vehicles Additional Insured Pay plan most interested in ---Annual6 MonthMonthly by MailMonthly EFTQuarterly If you have a copy of your current "Declaration Page", please forward that to us as proof of prior coverage and to use for comparison purposes. Submission of information for a quote in no way binds coverage. Personal information will be used solely for underwriting purposes. Submission of information gives the Gary J Bach Agency permission to run all reports necessary to quote accurate insurance premiums.