Home and Car insurance questionnaire
Please neatly complete this form & fax or email it back to my office
T-you, chris
The Across Atlanta Insurance Program
email csmith7750@yahoo.com
FAX(770) 321 - 1671 Office(404) – 514 – 0485
INSURANCE RELATED INFORMATION REQUESTED
-------------------------Related to home insurance----------------------------
current day ,evening and cellphone number
Current home address
Current e-mail address
Complete home address for new home if different then above
Mortgage Company’s loan officer name and phone number
CLAIMS – All claims in past 5 years for you as a homeowner or renter
Current Homeowners / renters insurance company name & policy number
ALL adults in householdlegal names, dates of birth, social security numbers
Related to car insurance--------------------------------------------------------------------------
DRIVERS LICENCE INFORMATION FOR LAST 3 YEARS
ALL LICENSE HOLDING DRIVERS IN THE HOME
Complete information on all drivers
Name’s as listed on current drivers license
drivers license numbers & statefor the last 3 years
Accident claim and ticket / moving violations history
Tickets (any moving violations) and any claims (weather your fault or not ) in the last 3 years for all drivers inhome
Drivers dates of birth and social security numbers of all drivers in the houshold
serial / vin numbers of each car in the household
confirm with the registration or from dashboard of car
Finance / lease company’s name & address if applicable
·IMPORTANT Please include a copy of a current car’s proof of insurance
( declaration page ) shows all cars &coverage’s