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 —Please choose an option—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: —Please choose an option—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 —Please choose an option—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.