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NEW QUOTES AND
POLICY REVIEW

Would you like to get a new quote or have us review your home or auto policy?

Auto Insurance
Policy Review »

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Online Auto Insurance Review

PLEASE TAKE THE TIME TO FULLY COMPLETE THIS FORM.
Questions? Call Jeanne Way at 231-547-4062 or 1-800-748-0414, or email Jeanne.

Automobile Insurance Questionnaire

Name*: Driver Lic#*:
Date of birth*: Occupation/Employer*:
Spouse Name: Driver Lic#:
Date of birth: Occupation/Employer:
Address*: City, State, Zip*:
Phone*:

Are you currently insured? YES NO
Current insurance company:
Do you have health insurance? YES NO
Health insurance company:

Please list all household members including name, date of birth and driver license#:

Please list Year, Make, Model, VIN and security features for each vehicle:

Is there a lien holder on any vehicle? YES NO
Do you lease any vehicles? YES NO

Please list all tickets/accidents/claims for all drivers in household in past 5 years:

Smoker? YES NO
Do you currently have an Umbrella policy? YES NO
Are you interested in rental car expense coverage? YES NO
Are you interested in Road Trouble Service Coverage? YES NO
What is your current Comprehensive Deductible?
Collision Deductible?

 

Thank you for taking the time to complete this online review. We promise to get back to you shortly!
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Bingham Insurance Services · 200 Antrim Street, P.O. Box 318 · Charlevoix, Michigan 49720
Phone: 231-547-4062 or 1-800-748-0414 · Fax: 231-547-0655 · Email Us
Member of Charlevoix Chamber of Commerce, Traverse City Chamber of Commerce & Beaver Island Chamber of Commerce
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Bingham Insurance Services