Auto Policy Protection Checklist
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Auto Policy Protection Checklist
Client Name
Address
City
State
Zip
Policy Number
Renewal Date of Policy
Email
Home Phone
Work Phone
Cell Phone
Please indicate Yes, No, or Insured meaning you already have the coverage.
Question 1
Do we insure ALL the vehicles you own?
Please Select
Yes
No
Insured
Question 2
Can we provide you with a FREE Instant Savings Comparison Proposal?
Please Select
Yes
No
Question 3
Are any vehicles NOT registered or titled in you and/or your spouse’s name?
Please Select
Yes
No
Insured
If so which vehicle and whose name is on the title?
Question 4
Has any vehicle been customized or altered?
Please Select
Yes
No
Insured
Details
Question 5
If you own a pickup or van, does it contain customized equipment, camper, or shell?
Please Select
Yes
No
Insured
If yes, explain
Question 6
Do you own a mini-bike, moped, motorized scooter or motorcycle?
Please Select
Yes
No
Insured
If yes, explain
Question 7
Do you own any ATVs, boats, snowmobiles, SEADOO motor homes or trailers?
Please Select
Yes
No
Insured
If yes, explain
Question 8
Do you have any students away at college? If so, student name?
Please Select
Yes
No
Insured
If so, list Student Names
Question 9
Do you have a company vehicle provided to anyone in your household on a full-time basis? If so additional discounts may apply.
Please Select
Yes
No
Insured
Question 10
Would you be interested in adding or increasing your Accident & Death Benefit Limits?
Please Select
Yes
No
Insured
Question 11
If you don’t already have Rental Car Coverage, would you like to have a rental car provided for you if you get in an auto accident for about $20 per year per car?
Please Select
Yes
No
Insured
Question 12
Would you like to be reimbursed up to $100 if you have to have your car towed?
Please Select
Yes
No
Insured
If you don’t already have Road Side Assistance would you like to add it for about $6 per car per year?
Please Select
Yes
No
Question 13
Would you be interested in obtaining information on a $1,000,000 Umbrella Liability Insurance policy that would protect you in the event of a catastrophic accident for as little as $150 per year?
Please Select
Yes
No
Insured
Question 14
Would you like to SAVE 2% - 7% on your auto insurance by paying your premium in full or by paying your premium on the three-payment plan (paid in full within 60 days)(Discount Applies for Erie Insurance Policies only)?
Please Select
Yes
No
Insured
Question 15
Would you like to have your premium spread over 12 months and drafted from your checking account in order to have NO SERVICE FEES?
Please Select
Yes
No
Insured
Question 16
Would you like a FREE No Obligation Review of your families Life Insurance Needs?
Please Select
Yes
No
Insured
Question 17
Do you drive your car to work or school?
Please Select
Yes
No
About Vehicle #1
Vehicle #1 Year
Vehicle #1 Make
Vehicle #1 Model
V#1 How far do you drive one way to work or school? (Miles)
V#1 Annual Mileage
V#1 Who drives the car most often?
V#1 Do you use this car for business in any way?
Please Select
Yes
No
V#1 Name on Title of Car
About Vehicle #2
Vehicle #2 Year
Vehicle #2 Make
Vehicle #2 Model
V#2 How far do you drive one way to work or school?(Miles)
V#2 Annual Mileage
V#2 Who drives the car most often?
V#2 Do you use this car for business in any way?
Please Select
Yes
No
V#2 Name on Title of Car
About Vehicle #3
Vehicle #3 Year
Vehicle #3 Make
Vehicle #3 Model
V#3 How far do you drive one way to work or school? (Miles)
V#3 Annual Mileage
V#3 Who drives the car most often?
V#3 Do you use this car for business in any way?
Please Select
Yes
No
V#3 Name on Title of Car
List any additional cars you own which are not listed above:
Year
Make/Model
VIN
Name of Insurance Carrier
List additional cars
List all members of your Household:
Member #1 Name
Member #1 Date of Birth
Member #1 Relationship to You
Member#1 Licensed?
Please Select
Yes
No
Member #2 Name
Member#2 Date of Birth
Member#2 Relationship to You
Member#2 Licensed?
Please Select
Yes
No
Member #3 Name
Member#3 Date of Birth
Member#3 Relationship to You
Member#3 Licensed?
Please Select
Yes
No
Member #4 Name
Member#4 Date of Birth
Member#4 Relationship to You
Member#4 Licensed?
Please Select
Yes
No
Member #5 Name
Member#5 Date of Birth
Member#5 Relationship to You
Member#5 Licensed?
Please Select
Yes
No
Member #6 Name
Member#6 Date of Birth
Member#6 Relationship to You
Member#6 Licensed?
Please Select
Yes
No
List additional members
The name of the person that completed this form and the date. By typing your name and date below you are electronically signing this document acknowledging that all the information is true.
Name
Date
Do you have any additional comments?
Message
Thank you for completing this form. It is a very important part of your insurance protection. Your form will be reviewed to ensure we have all the information you indicated. If you have requested additional information we will contact you. If you would like to speak with a member of the O’Connor Insurance Team please check below.
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