Personal Lines Survey - Automobile
DRIVER INFORMATION
List ALL residents of the household, including students who live away from home, non-custodial children, and domestic help.
| Item |
Name |
Relationship |
Date of Birth |
Type of Driver’s License (if any) |
Live in household? (Y/N) |
Live away from household? (Y/N) |
1.
2.
3.
Do any resident regularly rent (not lease) vehicles for either short-term or long-term use? ___Yes ___ No
If yes, describe the types of vehicles rented, the rental agreements, duration of rental, and locations where the rental takes place.
VEHICLE INFORMATION
List ALL vehicles that any of the individuals listed above own or operate. Include vehicles supplied by their employers. If two or more individuals use the same vehicle, enter all applicable operators using the numbers from the driver information listing.
| Item |
Year and Make |
Operator(s) # |
Owner |
Covered by this policy? |
1.
2.
Attach a separate listing with the same information for additional vehicles, as needed.
If this policy is not to cover a listed vehicle, list the vehicle # and the policy that covers that vehicle.
| Vehicle # |
Insurance Carrier |
Policy Number |
Are any vehicles used in connection with business activities? ___ Yes ___ No
Is any vehicle regularly used to transport children and others, other than shared
car-pooling arrangements? ___ Yes ___ No
Is any vehicle used in racing activities? ___ Yes ___ No
