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| Date: Referred by: |
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| First Name: Last Name: |
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| Address: Apt./Unit: |
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| City: State: Zip: |
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| Home Phone: Work Phone: Cell: |
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| Email: Fax Number: |
| Add me to your E-mail list |
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| 1. Please list names of all residents in your household, including yourself and any licensed and/or unlicensed drivers, children, drivers away at school or drivers serving in the military away from home. |
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| Name: D.O.B. Married: Single: |
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| Licensed? Yes No / License or Permit # Date licensed: |
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| Name: D.O.B. Married: Single: |
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| Licensed? Yes No / License or Permit # Date licensed: |
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| Name: D.O.B. Married: Single: |
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| Licensed? Yes No / License or Permit # Date licensed: |
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| Name: D.O.B. Married: Single: |
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| Licensed? Yes No / License or Permit # Date licensed: |
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***Failure to include all drivers in the home (whether or not they drive your vehicles) may be considered fraudulent. Please disclose all drivers. ***
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2. Do any of the above household residents have their own auto policy? Yes No
(If yes, we will need a copy.) |
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| 3. Have you or any other drivers been licensed in another state in past 3 years? Yes No |
| If so, what state? Driver License # |
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| 4. Did any of the above drivers complete driver training? Yes No (Need certificate) |
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| 5. Did any of the above drivers complete defensive driver course? Yes No (Need certificate) |
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6. Do any of the above drivers qualify for good student discount? Yes No
(Need most recent report card) |
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| 7. Have there been any accidents (At-Fault or Not-At-Fault) within the preceding 5 years? |
| Yes No |
If you answered Yes to the previous question, please give information on dates, drivers, and brief explanation. We will need police reports and/or company payout letters. Please disclose all accidents whether or not you were paid.
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| 8. Have you or any other drivers been convicted of any moving violations within the past 5 years? |
| Yes No (If yes, please provide date and explanation below) |
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| 9. Have you or any other drivers had their driver’s license suspended within the past 5 years? |
| Yes No (Provide details on the date, length, and reason for suspension below) |
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| Any vandalism claims or cars stolen? (provide details below) |
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10. Please list all vehicles that you will be insuring under this policy, who will be driving them and how many miles they are driving.
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| Vehicle 1 (Make and Model): Year: Odometer: |
| VIN# Driver: Miles to work or school: |
| Comprehensive coverage desired? Yes No |
| Collision coverage desired? Yes No |
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| Vehicle 2 (Make and Model): Year: Odometer: |
| VIN# Driver: Miles to work or school: |
| Comprehensive coverage desired? Yes No |
| Collision coverage desired? Yes No |
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| Vehicle 3 (Make and Model): Year: Odometer: |
| VIN# Driver: Miles to work or school: |
| Comprehensive coverage desired? Yes No |
| Collision coverage desired? Yes No |
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| 11. Are any of the above vehicles leased or financed? Yes No (If leased, we need agreement) |
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| 12. Are any of the above vehicles equipped with airbags and/or automatic seat belts? Y N |
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| 13. Are any of the above vehicles equipped with an alarm system? Yes No |
| Factory installed? Yes No |
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| 14. Are any of the above vehicles equipped with window etching? Yes No |
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| 15. Please list employer information for all driving and non-driving residents in the household. |
| Driver Occupation |
| Employer Name and Address |
| Employers phone number |
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| Driver Occupation |
| Employer Name and Address |
| Employers phone number |
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| Driver Occupation |
| Employer Name and Address |
| Employers phone number |
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| Driver Occupation |
| Employer Name and Address |
| Employers phone number |
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| Driver Occupation |
| Employer Name and Address |
| Employers phone number |
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| 16. Please provide us with the Social Security numbers of all licensed and unlicensed drivers, below. |
| Name: Social Security # |
| Name: Social Security # |
| Name: Social Security # |
| Name: Social Security # |
| Name: Social Security # |
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| Coverages: For the questions below (17 - 23), please see the insurance agent for coverage questions and suggestions. If you are unsure, please leave blank. These questions will affect the rating of your policy. |
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| 17. Previous Insurance Co. Expiration date: |
| Reason for cancellation, if cancelled |
| Is prior policy being cancelled on non-renewal? |
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| 18. Have you had any insurance laps within the past 5 years? Yes No |
| How long was lapse? |
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| 19. Do you wish to purchase a Standard Policy or a Basic Policy (Extremely Low Coverage)? |
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| 20. Which lawsuit option would you prefer - verbal threshold or zero threshold? |
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| 21. Mercury Insurance offers Homeowner Discount to all homeowners. |
| Are you a homeowner? Yes No |
(We will need proof of ownership: copy of home insurance policy, deed, property tax bill, etc.)
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| 22. Limits of liability coverage on your current policy: |
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| 23. Are there any other vehicles in your household you are not looking to insure? Yes No |
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| By submitting this form, I, certify that all information above is true and accurate to the best of my knowledge. All household residents and their driving records have been disclosed. My driving record including all violations has been properly recorded. Further more, I also understand that in order to accurately rate my policy, SAS Insurance Agency, Inc. may obtain the Motor Vehicle Abstract, CLUE Report and/or Credit Report for myself and all other household residents and by signing below I am extending my authorization for them to do so. I understand that all my information provided will not be disclosed to anyone other than the agency, company, and its representatives. This information will not be used for any other purpose. |
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