|
|
Complete name |
|
|
|
|
Spouse Name
(If applicable) |
|
|
|
|
Marital Status |
|
|
|
|
Age |
|
|
|
|
Social Security
(Optional) |
|
|
|
|
Policy Term |
|
|
|
|
Postal Address |
|
|
|
|
Zip Code |
|
|
|
|
AARP member number |
|
|
|
|
Phone
number |
|
|
|
|
Work phone |
|
|
|
|
Mobile phone |
|
|
|
|
Fax |
|
|
|
|
E-mail |
|
|
|
|
Occupation |
|
|
|
|
Do you have a homeowner or Dwelling policy
through our AARP program?
|
|
|
|
Please Provide Policy
number:
|
|
|
|
Coverages |
|
|
|
Please select your coverage: |
|
|
|
|
Towing & Labor: |
|
|
|
|
|
|
|
|
|
Liability Limits |
|
|
|
Bodily Injury & Property Damage
Combined Single Limit: |
$100,000 Per
Occurrence |
|
|
|
Note: If you have selected the Combined
Single Limit option above,
please do not select
any other option
below except Medical Payments if you wish
that coverage. |
|
|
|
Bodily Injury limit: |
|
|
|
|
Property Damage limit: |
|
|
|
|
Medical Coverage limit: |
|
|
|
|
|
|
Description of Automobiles |
|
|
|
Automobile #1 |
|
|
|
|
|
|
|
Automobile #2 |
|
|
|
|
|
|
|
Automobile #3 |
|
|
|
|
|
|
|
|
|
|
|
Persons that reside in your home & drive the
insured automobile |
|
|
|
Information
driver #1:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1. Does the Insured or any driver
have any physical impairment? |
|
|
2 During the past 5 years has any
company cancelled or not renewed
your policy? |
|
|
3. Have you or any driver been
charged with a traffic violation in
the past 5 years? |
|
|
4. Has your license or that of any
driver has been suspended? |
|
|
5. Do you or your spouse own any
other personal automobile? |
|
|
6. Do you have any other policy
through our AARP Program? |
|
|
|
| 8.
Please provide name and
policy number of the Company
who previously insured your
vehicle(s). |
|
|
|
|
|
|
NOTIFICATION DISCLAIMER
|
|
|
|
|
|
|
|
Notification:
Important notice regarding the fair credit
reporting act: In this application for
insurance it is understood that as a part of
our underwriting procedure, an investigate
consumer report may be prepared
whereby information is obtained through
personal interviews with your neighbors ,
friends, or other with whom you are
acquainted. This inquiry includes
information as to your character, general
reputation, personal characteristic and mode
of living. If an investigation is made you
can be assured that it will be handle in the
strictest confidence. If you information on
the nature and scope of the customer report
which may be requested, ask your agent for
the address of the company handling your
account.
|
|
|
|
comments: |
|
|
