YES NO
2. Are there any motorized vehicles (Private Passenger, Commercial Automobiles, or Recreational Motor Vehicles), which are owned, leased or regularly furnished to the applicant or spouse that are not covered by underlying policies? If yes, please list.
YES NO LIST:
LIST:
3. Has any member of the household ever had insurance in an automobile assigned risk program? Ex: High Risk Car Insurance
4. Is any member of the household an excluded driver on an underlying auto policy?
5. Has any driver or member of the household received a ticket for speeding or any other vehicle code violation within the last 5 years?
6. Has any driver or member of the household, while driving a motor vehicle, been involved in an accident or reported a claim to an insurance company during the last 5 years?
7. Has any member of the household had any license suspensions within the past 5 years?
8. Does any member of the household participate in automobile, recreational vehicle or watercraft races, contests or exhibitions?
9. Has any member of the household had any primary or excess liability insurance cancelled or denied within the past 5 years?
10. Does any member of the household serve as an officer or member of the Board of Directors of a non-profit corporation or organization?
11. Do you employ any domestic workers?
12. Is there any incidental business exposure, example; Avon, Amway, Longenberger?
13. Do you have any lawsuits currently pending?
14. Do you have any aircraft exposure or watercraft exposure?
15. Any members of the household newly licensed within the last year?
16. Any unusual hazards, ex: pools, trampolines, lakes, and ponds?
17. Do you require uninsured/underinsured motorist coverage under the personal catastrophe policy?
18. Do you have any problems, questions or concerns?
Name:
Policy #:
Phone #:
Email Address:
Date: (format: DD/MM/YYYY)
