AFFIRMATIVE INSURANCE SERVICES 5624 Lankershim Blvd., North Hollywood, Los Angeles, California-91601. Phone: 818-997-7879 Fax: 818-997-7844 EMAIL: info@getais.com PERSONAL AUTO WORKSHEET First Name: Last Name: Garaging Address: Garaging City: Garaging State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Garaging Zip Code: Phone Number: Fax Number: E-Mail Address: Who Referred You to Our Site? MAILING ADDRESS (OPTIONAL) Mailing Address (If Different from Garaging): Mailing City: Mailing State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Mailing Zip Code: DRIVER INFORMATION Driver One Driver Two Driver Three Driver Four First Name Birthdate Social Security Sex Male Female Male Female Male Female Male Female Marital Status Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Single Married Divorced Widowed Separated Yrs Licensed State Licensed Drivers License #: Occupation VEHICLE INFORMATION Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Year Make Model I.D. # Miles Driven OneWay To Work Miles Driven Each Year Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+ Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+ Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+ Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+ Ownership Leased Paid-Off Financed Leased Paid-Off Financed Leased Paid-Off Financed Leased Paid-Off Financed VIOLATION INFORMATION Last 3 Yrs (Minors)Last 5 Yrs (Majors) Driver 1 Driver 2 Driver 3 Driver 4 Minor Violations - Speeding,Turn, Stop Sign, Red Light, etc. None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 Accidents - Non Chargeable None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 Accidents - Chargeable None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 Major Violations - Drunk Driving,Reckless, Hit & Run, etc. None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 None 1 2 3 4 COVERAGE INFORMATION Bodily Injury Property Damage Personal Liability 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000 5,000 10,000 25,000 50,000 100,000 Uninsured Motorist No Coverage 15,000/30,000 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,000 No Coverage 3,500 Deductible Waiver Medical Payment: No Coverage 1,000 2,000 2,500 5,000 10,000 15,000 20,000 25,000 50,000 100,000 DEDUCTIBLE INFORMATION Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Comp (Theft) No Coverage 250 500 1,000 1,500 2,000 No Coverage 250 500 1,000 1,500 2,000 No Coverage 250 500 1,000 1,500 2,000 No Coverage 250 500 1,000 1,500 2,000 Collision No Coverage 250 500 1,000 1,500 2,000 No Coverage 250 500 1,000 1,500 2,000 No Coverage 250 500 1,000 1,500 2,000 No Coverage 250 500 1,000 1,500 2,000 MISCELLANEOUS INFORMATION Current Insurance Company: Expiration Date: Current Premium $: Questions or Comments to help the Agent: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.
Mailing Address (If Different from Garaging):
Bodily Injury
Property Damage
Current Insurance Company: