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Home » Insurance Questions Form

Insurance Questions Form

Name(Required)
Does any operator have any medical, nervous, mental, or physical conditions which would impair his or her ability to safely operate a vehicle in any way (including seizures, convulsions, blackouts, loss of consciousness, fainting, etc.)?(Required)
Will any vehicle be used for any business or delivery purposes including, but not limited to making sales calls, driving to job sites, pizza, telephone directory or newspaper delivery?(Required)
Have all residents of your household age 16 and older been listed on this application? If no, please explain in the comments section below. Use the comment section to list all household members.(Required)
Have all drivers who may operate your vehicles on a regular or infrequent basis, including children away from home, been listed on this application?(Required)
Do you understand that acceptable proof for all applicable discounts must be provided and that each driver must qualify for these discounts to be awarded when your policy is issued by the Company (lapses in coverage may be verified)?(Required)
Do you understand that any non-factory installed special equipment, which has not been declared on the application with a premium charge, is not covered?(Required)
Are any of the drivers in your household a Registered Domestic Partner?(Required)
Do you understand that failure to truthfully and accurately complete this application, including the above questions jeopardizes my insurance coverage?(Required)
Motor Club
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