Académique Documents
Professionnel Documents
Culture Documents
DATE: ________________
1. What brings you to Allstate? 2. What has you shopping for car insurance? 3. Are we the first company you called for a
quote?
Legal Name ___________________________________________________________________________________________________
Address ______________________________________________________________________________________________________
Phone ____________________Work ____________________ Cell _________________ E-Mail ______________________________
4. Who is your current insurance provider and are you satisfied with your agent?
PRIOR INSURANCE: _________________Policy No.: _________________ How Long: ________Expiration Date: ____________
AUTOS
Year
Make
Model
VIN
(For Motorcycles need CCs and for Motorhomes need the value)
Lien?
Date Purch
1. __________________________________________________________________________________________________________________________
2. __________________________________________________________________________________________________________________________
3. __________________________________________________________________________________________________________________________
4. __________________________________________________________________________________________________________________________
DRIVERS
Name
Drivers License
DOB
SSN
Tickets/Acc in 5 yrs
1. ___________________________________________________________/______/_______________________________________________________
2. __________________________________________________________ /______ /_______________________________________________________
3. __________________________________________________________/_______/_______________________________________________________
4. __________________________________________________________/_______/_______________________________________________________
OCCUPATIONS: __________________________________________________________________________________
(Good Hands Discount for certain occupations and for retirees)
Children in HH, Name & DOB: ______________________________________________________________________
COVERAGES:
Car 1
Car 2
Car 3
Car 4
BI
_____/_____
Same
Same
Same
PD
__________
Same
Same
Same
UM BI
_____/_____
Same
Same
Same
UM PD
__________
Same
Same
Same
MED
__________
Same
Same
Same
COLL
__________
__________
__________
__________
COMP
__________
__________
__________
__________
TOW
__________
__________
__________
__________
RENTAL
__________
__________
__________
__________
(TN Only)
YD with B average?
If YD in HH offer Teensmart
Y or N
5. How much do you currently pay for auto insurance? 6. Other than price, what is important to you in your auto insurance?
Notes: