Updated: 08/22/08 1997

SRIA/LR
Smith-Reagan Insurance Agency
148 N. Sam Houston Blvd. P O Box 1009
San Benito, Texas 78586
(956) 399-1353 FAX (956) 399-2185
AUTOMOBILE UNDERWRITING QUESTIONNAIRE
Applicants name: _________________________ Co-Applicant: ___________________ Phone #: ___________
Mailing Address: ______________________________ City:___________________ ST:_____ Zip Code:______
Physical Address: ______________________________ check if same as above
How long at current address? ______ Do you own your home? Y N Is it insured? Y N
If less than 5 years at current address, provide prior address: _______________________________________________
LIST ALL MEMBERS OF HOUSEHOLD, INCLUDING YOURSELF, LICENSED OR NOT.
Name
Date of
Birth
Marital
Status
Defensive
Driving?
Yrs w/
license
Drivers License
& State
Social Security #
1 Y N
2 Y N
3 Y N
4 Y N
EMPLOYMENT INFORMATION
Occupation
Years
employed
Employer Name and Address
Work Phone #
1
2
3
4

P r i o r I n s u r a n c e C o m p a n y
How long with company? P r i o r p o l i c y # Expiration Date
___yrs ___months
PREVIOUS COVERAGE
check if NO INSURANCE if NO INSURANCE, please explain ______________________________________

VEHICLE INFORMATION

Veh
Year, Make and Model Vehicle Identification #
Date
Purch
New/
Used
1
2
3
4

Veh
Cost New
How is vehicle used?
Please check the one that applies
Anti Lock
Brakes?
Auto
Seat Belts?
Airbags?
Yes No
Alarm System? Yes No
Describe alarm functions:
1 $
to & from work pleasure business
Y N Y N driverboth
2 $
to & from work pleasure business
Y N Y N driverboth
3 $
to & from work pleasure business
Y N Y N driverboth
4 $
to & from work pleasure business
Y N Y N driverboth

Veh
Who is principal
operator?
Who is title owner?

Is there any
damage?
Odometer
Reading
Is there any custom equipment? Yes No
(i.e.: stereo, tires, rims, etc.) Value of each:
1 Y N $
2 Y N $
3 Y N $
4 Y N $
LIENHOLDER
Check if NONE

Veh
Name and Address
Loan # (if any)
1
2
3
4
LIMITS DESIRED
Liability Limits- Umbrella coverage desired? Y N
Bodily Injury /Property Damage $_________________________ (Primary Auto must be at least 250/500/100)
Uninsured Motorists- Limit $__________________________
Bodily Injury /Property Damage $_________________________
Medical / Personal Injury Protection $______________________ ATVs? Y N
Comprehensive (Deductible) $_________________________
Collision (Deductible) $___________________________________
Rental? Y N Towing? Y N
ADDITIONAL INFORMATION NEEDED ON OPPOSITE PAGE
PLEASE COMPLETE
For Office Use Only:
Producer:______________________
______
Date:_________________________
_______
Date Quote
Needed:_________________
Updated: 08/22/08 1997
SRIA/LR

ACCIDENTS/CONVICTIONS (in the last 5 years) (i.e.: speeding ran red/stop sign, accident, hit and run)
Check if NONE
Dvr Date of
Accident/Conviction
Description of Accident or Conviction Location Amount Paid
1 $
2 $
3 $
CLAIMS PAID (list any claims paid by insurance company in the last 5 years) check if NONE
Dvr Date of Claim Description of Claim Location Amount Paid
1 $
2 $
3 $

CLAIMS LOSS UNDERWRITING EXCHANGE QUESTIONNAIRE

1. With regard to your automobile(s), in the past 5 years have you or any member of your household been a victim of a crime or an
accident? YES NO

2. When was the last time you or any member of your household was involved in an accident? Please be as specific as possible:
______________________________________________________________________________________________________
Please use the space below to explain the accidents:
______________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________

3. In the past 5 years, have any of your automobiles been hit while parked, had a broken window, been stolen, had wind, hail, or fire
damage? YES NO

4. Have you filed for Bankruptcy in the last 10 years? YES NO If so, what year? _________


REIMBURSEMENT DISCLOSURE FORM

This agency performs the following services to assist in placing coverage:

The agency orders Motor Vehicle Records (MVRs) on file with the Department of Public Safety for all persons
listed as drivers of covered automobiles. By law, the agency must furnish a copy of the MVRs.

Article 21.35B of the Texas Insurance Code permits the agency to charge a reimbursement fee to actual costs associated with these
services. The agency must obtain written consent before incurring the expenses.

$7.50 per Motor Vehicle Report THIS AMOUNT WILL BE COLLECTED ONLY IF YOU DECIDE TO INITIATE
COVERAGE

Signed ____________________________________________________________ Date ________________


The Insurance Company Underwriter reviewing your application must thoroughly review the application and investigate all areas of
exposure. Three major areas which the insurance company underwriter will research are:

Motor Vehicle Report (MVR) - This report from the Texas Department of Public Safety (or similar law enforcement in
other states) will show your driving record, date first licensed, any tickets or accidents, driver training schools. etc. . .

C.L.U.E. Report (Comprehensive Loss Underwriting Exhibit) - The CLUE report provides a summary of all amounts
paid by your previous auto and home insurance companies. The report also summarizes all claims and incidents
involving a.) anyone at the same address, b.) all claims paid on a vehicle I.D. number (V.I.N.). The report also
indicates all licensed drivers registered at your present address, according to the Test Department of Public Safety. (Or
similar law enforcement agency).

Credit Report - Reports information usually found on most credit reports such as, but not limited to, your payment
history to creditors, moneys charged-off as not collectible by your creditors, bankruptcy, and any other adverse
credit.

The insurance companies to which we submit your application have assured us that the information will be handled in the strictest
confidence. Our agency does not receive copies of the credit report or the CLUE report

My agent has explained the underwriting process and the ordering of the above reports. To the best of my
knowledge, the above information is correct.

______________________________ ________________________________
Applicants Signature Date