Personal Auto Insurance Intake Questionnaire - Almeida and Carlson Insurance Agency

Greetings! In order to provide an accurate rating for an Auto insurance quote, please answer the following questions:

Named Insured(s):

Named Insured (Vehicle owner):(Required)

First Last

Effective date of coverage:

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Do you currently have a Personal Auto policy? If not, why? (Nonpayment, underwriting, new purchase?)

If yes, what carrier?:

Years with carrier?:

Do you have AAA and/or AARP?:

Do you drive for Lyft, Uber, or Door Dash?:

How Is Premium Paid?

EFT

Paid in Full

By Mail

Auto policy details:

Driver/s:

Name

Date of Birth

License

Good Student

*All licensed household members should be included, even if they have their own policy. Click (+) to add additional names.

*Have you been licensed outside of MA?

If so, whom, what state, and what was the license number?

Vehicle(s):

Year

Make

Model

VIN

Garaging

Click (+) to add additional vehicles.

Trailer – additional questions:

Year/Make/Model and VIN (or Homemade?):

Type (boat/utility/dump/etc)

Gross Vehicle Weight (GVW):

Value of trailer:

Liability only or include collision & comprehensive:

Motorcycle – additional questions:

Year/Make/Model and VIN:

Purchase price/value:

CCs:

How many years of experience?

Do you have a motorcycle training certificate?

RV – additional questions:

Year/Make/Model and VIN:

Purchase price/value:

Liability only or include physical damage coverage (collision & comprehensive):

*Please be sure to answer all applicable questions to help ensure accurate rating. If you have a current policy and would provide us with a copy it will help expedite the quoting process. Thank you for choosing Almeida & Carlson Insurance Agency for your insurance needs!

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