Thank you for your interest in Automotive Insurance products from the Larry N. George Agency, Inc. Please answer all of the questions that apply to you in all four parts of the form below. Simply click on the Submit button at the bottom of the screen to send your information to us. One of our licensed staff will respond to you as soon as we receive your results.

Part 1. Describe Yourself
In this section, we need you to tell us about yourself. All information collected will be kept confidential and will only be used to process your request.

Full Name *
Street Address *
City *
State/Province *
Zip/Postal Code *
County *
Work Phone
E-mail Address: *
Home/Cell Phone *
Date of Birth
Gender *Male
Female
How long have you lived at your current address?
Enter the name of your current insurance provider.
Enter the expiration date of your current policy.
What is the total number of residents in your household?
 

Part 2. Household Driver Information
Here we ask that you answer questions about the licensed drivers in your household. If there are more than four you may discuss that with one of our licensed professional staff.


What is the total number of licensed drivers in the household age 15 and over?

 

 


 

Driver #1 Name
Date of Birth
GenderMale
Female
Drivers License Number
How many years driving experience?
Driver #2 Name
Date of Birth
GenderMale
Female
Drivers License Number
How many years driving experience?
Driver #3 Name
Date of Birth
GenderMale
Female
Drivers License Number
How many years driving experience?
Driver #4 Name
Date of Birth
GenderMale
Female
Drivers License Number
How many years driving experience?
 

Part 3. Driver History 
Here we ask that you tell us about the driving history of all licensed drivers in your household.


Has any driver in your household had auto insurance refused, cancelled, expired or been excluded or restricted from a policy in the last three years? If YES, please provide the name of the company, a short explanation (non-pay, frequency of accidents, etc.) and the date by month/year.

 


 

Has any driver had their driving privileges suspended or revoked in the last 3 years?Yes
No
If yes, provide the name of the driver here.
Enter the date of suspension or revocation
If 2, provide name of the second driver here.
Enter the date of the suspension or revocation.
If 3, provide name of the third driver here.
Enter the date of the suspension or revocation.
Has any driver received a speeding ticket in the last 3 years?Yes
No
Enter the date of the 1st ticket.
Provide the driver name and a description of the first ticket.
Enter the date of the 2nd ticket.
Provide the driver name and a description of the second ticket.
Enter the date of the 3rd ticket.
Provide the driver name and a description of the third ticket.
Has any driver been arrested in the past 3 years?Yes
No
Does any driver have any of the following physical or mental impairments: heart, diabetes, epilepsy/hearing /sight/limb loss, back conditions or other conditions that you receive regular treatments or medication? If yes, please describe:
Has any driver incurred comprehensive losses or claims such as fire, deer, glass breakage, etc. in the last 5 years? If yes, please describe:
Has any driver been involved in an accident or reported a claim to an insurance company in the last five years? (if no skip to Part 4)Yes
No
If yes please give a short description, regardless of who was at fault, including the drivers name and the date for the first accident.
If more than 1 please give a short description, regardless of who was at fault, including the drivers name and the date for the second accident.
If more than 2 please give a short description, regardless of who was at fault, including the drivers name and the date for the third accident.
If more than 3 please give a short description, regardless of who was at fault, including the drivers name and the date for the fourth accident.
 

Part 4. Vehicle Information
Here we ask you to tell us about the vehicles you would like to insure with us.
Make (ex. Ford, Chevy, Dodge, Honda)
Model (ex. Ranger, Cavalier, Ram, Accord)

Enter the Year, Make & Model of the 1st vehicle.

 

 

 

Enter the amount of miles this car is driven one way to work or school daily.
Enter the Year, Make & Model of the 2nd vehicle.
Enter the amount of miles this car is driven one way to work or school daily.
Enter the Year, Make & Model of the 3rd vehicle.
Enter the amount of miles this car is driven one way to work or school daily.
* Required

The Larry N. George Agency, Inc. | www.georgeagency.com