Questionnaire Selection Coverage List

PERSONAL AUTO

List ALL residents of the household including students living away from home, non-custodial children and domestic help.

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List ALL vehicles owned or operated by any of the individuals listed above. Include vehicles supplied to the individuals by their employers. If more than one of the above individuals use the same vehicle enter all applicable operator numbers.

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6. _______________________________________________________________________________________________

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If a vehicle is not covered by this policy, list the vehicle and the policy that covers that vehicle.

Vehicle #                     Insurance carrier                                  Policy #

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Does any insured regularly travel outside of the United States?

If yes, answer the following questions:

Does the insured drive vehicles when outside the United States? __Yes __No

Does the insured purchase insurance coverage in those countries? __ Yes __ No

Are any vehicles used in connection with business activities? __Yes ___ No

If yes, describe the business and how the vehicle is used:

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Is any vehicle used to snow plow or tow for others? __Yes ___No

If yes, which vehicle and how is it used:

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Is any vehicle used to transport children and others on a regular basis other than shared car pooling arrangements?
__Yes __ No

If yes, which vehicles and describe the activities:

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Is any vehicle used in racing activities? ___ Yes ___ No

If yes, which vehicled how is it used:

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Are any of the vehicles temporarily out of service? ___ Yes ___ No

If yes, which vehicle and why is it out of service?

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Are any of the vehicles considered antique or classic cars? ___ Yes ___ No

If yes, which vehicle and how many miles is it driven annually, how is it used and describe the restoration and customization?

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Do any insureds rent (not lease) vehicles for either short- or long-term use? ___Yes ___ No

If yes, please describe the rental agreements, the vehicles rented, length of time and locations.

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