Personal Automobile Questionnaire
Please fill in the spaces as indicated below:
Georgia Residence Only
Your Name
Address
City
County
Zip
Telephone #
Fax #
E-mail
Personal Automobile Application and detailed data
Driver Information
Driver # 1 Name:
Age:
Driver's Sex:
Male:
Female:
Married:
Yes:
No:
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Driver # 2 Name:
Age:
Driver's Sex:
Male:
Female:
Married:
Yes:
No:
**************************
Driver # 3 Name:
Age:
Driver's Sex:
Male:
Female:
Married:
Yes:
No:
Accidents and Violatioins: List all for the last 3 years
for all Drivers:
Vehicle Information
Vehicle #1: Year
Make & Model:
Vehicle #2: Year
Make & Model:
Vehicle #3: Year
Make & Model:
**************************
Vehicle #1: Use
Pleasure
Drive to work
Use in Business
Used on Farm
Miles to Work:
Vehicle #1: Use
Pleasure
Drive to work
Use in Business
Used on Farm
Miles to Work:
Vehicle #1: Use
Pleasure
Drive to work
Use in Business
Used on Farm
Miles to Work:
Vehicle Coverage
Liability Coverage
Split Limits
Single Limits
15/30/10
40,000
25/50/25
50,000
50/100/50
100,000
100/300/100
300,000
250/500/250
500,000
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Uninsured Motorist Coverage
Split Limits
Single Limits
15/30/10
40,000
25/50/25
50,000
50/100/50
100,000
100/300/100
300,000
250/500/250
500,000
