Joseph H. McGlone, Inc.
Insurance Analyst

Customer Information

   

Please choose:	Mr.,Mrs.,or Ms. Mr. Mrs. Ms.
Last name:		First name:
Address:
City, State, Zip:
E-mail address:
Home phone:		Work phone:

 

Vehicle # 1 Information

Make of car         Model       Year

 

Vehicle Identification Number

 

Body style Select Sedan Coupe Hatchback Convertible SUV Truck Van Mini van StationWagon Other         Doors  Select two three four        Cylinders  Select 4 6 8 12

 

Passenger protection Select regular seatbelts automatic seatbelts drivers side airbag dual airbags other    Antitheft Device Select None Factory alarm Lo jack Onstar Teletrak The Club other

 

Vehicle is owned or vehicle is leased       Total annual miles

 

Vehicle used for:

 

pleasure      business         what type of business commuting      (to work, school, or mass transit center)             If used for commuting where to? (street, city, state, zip) Vehicle is used days per week to commute miles (one way)

 

Vehicle # 2 Information

Make of car         Model       Year

 

Vehicle Identification Number

 

Body style Select Sedan Coupe Hatchback Convertible SUV Truck Van Mini van StationWagon Other         Doors  Select two three four        Cylinders  Select 4 6 8 12

 

Passenger protection Select regular seatbelts automatic seatbelts drivers side airbag dual airbags other    Antitheft Device Select None Factory alarm Lo jack Onstar Teletrak The Club other

 

Vehicle is owned or vehicle is leased       Total annual miles

 

Vehicle used for:

 

pleasure      business         what type of business commuting      (to work, school, or mass transit center)             If used for commuting where to? (street, city, state, zip) Vehicle is used days per week to commute miles (one way)

 

Vehicle # 3 Information

Make of car         Model       Year

 

Vehicle Identification Number

 

Body style Select Sedan Coupe Hatchback Convertible SUV Truck Van Mini van StationWagon Other         Doors  Select two three four        Cylinders  Select 4 6 8 12

 

Passenger protection Select regular seatbelts automatic seatbelts drivers side airbag dual airbags other    Antitheft Device Select None Factory alarm Lo jack Onstar Teletrak The Club other

 

Vehicle is owned or vehicle is leased       Total annual miles

 

Vehicle used for:

 

pleasure      business         what type of business commuting      (to work, school, or mass transit center)             If used for commuting where to? (street, city, state, zip) Vehicle is used days per week to commute miles (one way)

 

Driver Information

Provide information for ALL licensed residents living in your household.

 

	Driver 1	Driver 2	Driver 3	Driver 4
Name
Relationship to # 1		Select Spouse Child Parent Sibling Other	Select Spouse Child Parent Sibling Other	Select Spouse Child Parent Sibling Other
Occupation
Sex	Select Male Female	Select Male Female	Select Male Female	Select Male Female
Date of birth
Marital status	Select single married divorced separated	Select single married divorced separated	Select single married divorced separated	Select single married divorced separated
** Drivers license #
** Social security #
Total yrs. licensed
Tickets last 3 yrs	Select 0 1 2 3 4 5 6 6+	Select 0 1 2 3 4 5 6 6+	Select 0 1 2 3 4 5 6 6+	Select 0 1 2 3 4 5 6 6+
Accidents last 3 yrs	Select 0 1 2 3 4 5 6 6+	Select 0 1 2 3 4 5 6 6+	Select 0 1 2 3 4 5 6 6+	Select 0 1 2 3 4 5 6 6+

 

          ** this information is optional -(used to determine eligibility for preferred program)

Please list all accidents and violations below.  The list should include approximate dates, points, description, and amount paid by your insurance company to you or another party.  For example: 10/4/99 speeding ticket 13 miles over the limit for 2 points. or 5/1/00  I rear ended another party and my company paid them $1300.

 

Current Insurance Information

Present Insurance Company   How long with current carrier  Expiration date      OR   Cancellation date Is this policy currently in force  yes   no

 

Coverage Requested

Collision Deductible  $250 $500 $1,000 Select           Comprehensive Deductible  $250 $500 $1,000 Select Split Liability Limits  $25,000/50,000/25,000 $50,000/100,000/50,000 $100,000/300,000/50,000 $250,000/500,000/100,000 Select or other       OR Combined Single Liability Limit $35,000 $50,000 $100,000 $300,000 $500,000 Select   or other