Please
answer the following questions:
Are you currently
insured?
Yes No
If "Yes", when does your current policy expire?
If "Yes", who are you currently insured with?
Have you taken a driver safety course?
Yes
No
Any Accidents?
No
Not At Fault Accident
At Fault Accident
How long since last accident?
Less than one year
Between one and two years ago
Between two and three years ago
More than three years ago
Does the vehicle have an alarm?
No
Active (Driver-Activated Ignition Disabling)
Passive (Automatic Ignition Disabling)
Alarm Only (No Ignition Disabling)
Lojack (Vehicle Recovery System)
What is the primary use?
Pleasure
Commute
Business (Corporate)
Business (Individual)
Government
Competition
What is your Marital Status?
Married
Single
Widowed
Divorced
Separated
Rate your own credit
Excellent
Minor problems
Bad
Horrible
Vehicle Make
Vehicle Model
Year Built
VIN #
Purchase Price
Current Value
How many miles a year do you drive?
Less than 5000
5000 - 10000
10000 - 20000
20000 - 30000
30000 - 40000
30000 - 40000
40000 - 50000
More than 50000
If Auto, is your car equipped with antilock brakes?
No
All-Wheel Anti-Lock
Rear-Wheel Only
Front-Wheel Only
Not Sure
If Auto, is your car equipped with airbags?
No
Driver's and Passenger's Side Only
Driver's Side Only
Passenger's Side Only
Driver's, Passenger's and Side Impact
If RV, are you a member of any of these associations?
No
AAA-Plus
Campers Club of America
Camping World President's Club
Escapees
Flying J
Family Motor Coach Association
Good Sams Club
Manufacturers Club
RPI
Thousand Tails
Additional
Drivers?
Include in Quote Don't Include
Number of Drivers
Name of Additional Driver
/ / Birth Date (mm/dd/yyyy)
Any Accidents?
No
Not At Fault Accident
At Fault Accident
Any Moving Violations?
Never
1
2
3
4
5 or more
Name of Additional Driver
/ / Birth Date (mm/dd/yyyy)
Any Accidents?
No
Not At Fault Accident
At Fault Accident
Any Moving Violations?
Never
1
2
3
4
5 or more
Name of Additional Driver
/ / Birth Date (mm/dd/yyyy)
Any Accidents?
No
Not At Fault Accident
At Fault Accident
Any Moving Violations?
Never
1
2
3
4
5 or more
Additional
Vehicles?
Include in Quote Don't Include
Vehicle Make
Vehicle Model
Year Built
VIN #
How many miles a year do you drive?
Less than 5000
5000 - 10000
10000 - 20000
20000 - 30000
30000 - 40000
30000 - 40000
40000 - 50000
More than 50000
Does the vehicle have an alarm?
No
Active (Driver-Activated Ignition Disabling)
Passive (Automatic Ignition Disabling)
Alarm Only (No Ignition Disabling)
Lojack (Vehicle Recovery System)
What is the primary use?
Pleasure
Commute
Business (Corporate)
Business (Individual)
Government
Competition
If Auto, is your car equipped with antilock brakes?
No
All-Wheel Anti-Lock
Rear-Wheel Only
Front-Wheel Only
Not Sure
If Auto, is your car equipped with airbags?
No
Driver's and Passenger's Side Only
Driver's Side Only
Passenger's Side Only
Driver's, Passenger's and Side Impact
Vehicle Make
Vehicle Model
Year Built
VIN #
How many miles a year do you drive?
Less than 5000
5000 - 10000
10000 - 20000
20000 - 30000
30000 - 40000
30000 - 40000
40000 - 50000
More than 50000
Does the vehicle have an alarm?
No
Active (Driver-Activated Ignition Disabling)
Passive (Automatic Ignition Disabling)
Alarm Only (No Ignition Disabling)
Lojack (Vehicle Recovery System)
What is the primary use?
Pleasure
Commute
Business (Corporate)
Business (Individual)
Government
Competition
If Auto, is your car equipped with antilock brakes?
No
All-Wheel Anti-Lock
Rear-Wheel Only
Front-Wheel Only
Not Sure
If Auto, is your car equipped with airbags?
No
Driver's and Passenger's Side Only
Driver's Side Only
Passenger's Side Only
Driver's, Passenger's and Side Impact
Details
When would you like to be contacted?
Morning
Afternoon
Evening
Any Time
Any
Comments / Questions?
Want to receive relevant
information from Concise Insurance Services?
Yes
No