Casualty Pros Auto Questionnaire

Auto Survey
Name*

First NameMiddle NameLast NameSuffix
Who is your current insurance company?
Approximately how long have you been insured with your current company?
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
Example@gmail.com
Phone Number*

Area CodePhone Number
Drivers
How many drivers are in your household?*

OneTwoThreeFour
Driver #1*

First NameMiddle NameLast NameSuffix
Driver #1 DOB*

MonthDayYear
Date
Driver #1 License No.*
Driver #1 Industry/Job *
Driver #1 Education*
Driver #2

First NameMiddle NameLast NameSuffix
Driver #2 DOB

MonthDayYear
Date
Driver #2 License No.
Driver #2 Industry/Job
Driver #2 Education
Driver #3

First NameMiddle NameLast NameSuffix
Driver #3 DOB

MonthDayYear
Date
Driver #3 License No.
Driver #3 Industry/Job
Driver #3 Education
Driver #4

First NameMiddle NameLast NameSuffix
Driver #4 DOB

MonthDayYear
Date
Driver #4 License No.
Driver #4 Industry/Job
Driver #4 Education
How many vehicles to be covered?*

OneTwoThreeFour
Vehicle #1
Vehicle #1 Make*
Vehicle #1 Model*
Vehicle #1 VIN
Vehicle Color*
Annual Miles Driven*
Vehicle Use*
Lienholder Vehicle #1
If None use N/A
Vehicle #2
Vehicle #2 VIN
Vehicle #2 Make
Vehicle #2 Model
Vehicle #2 Year
Annual Miles Driven
Vehicle Color
Vehicle Use
Lienholder Vehicle #2
If None use NA
Vehicle #3
Vehicle #3 VIN
Vehicle #3 Make
Vehicle #3 Model
Vehicle #3 Year
Annual Miles Driven
Vehicle Color
Vehicle Use
Lienholder Vehicle #3
If None use NA
Vehicle #4
Vehicle #4 VIN
Vehicle #4 Make
Vehicle #4 Model
Vehicle Color
Vehicle #4 Year
Vehicle Use
Lienholder Vehicle #4
If None use NA
Are you currently enrolled in telematics? Would you be interested if there was a considerable discount?*
Has anyone had any tickets or accidents in the last 5 years?*

YesNo
If Yes, please describe in detail
Any other auto claims in the last 5 years?*

YesNo
If Yes, please describe in detail
Are any autos used for ridesharing services such as Uber or Lyft?*

YesNo
If Yes, please describe
Are any vehicles used for deliveries or any commercial purpose?*

YesNo
If Yes, please describe
Is anyone require to have an SR-22 filing?*

YesNo
Optional: Please Upload Current Insurance Dec Page

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Auto Survey

Drivers

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4