Name
Phone
6650 Reseda Blvd
Suite #108
Reseda, CA 91335
contact@gisinsure.com
Auto Insurance
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Last Name:
Garaging Address:
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Garaging Zip Code:
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Who Referred You to Our Site?
Driver Information
Driver One
Driver Two
Driver Three
Driver Four
First Name
Birthdate
Social Security
Sex
Male
Female
Male
Female
Male
Female
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Separated
Single
Married
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Separated
Single
Married
Divorced
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Separated
Single
Married
Divorced
Widowed
Separated
Yrs Licensed
State Licensed
Drivers License #:
Occupation
Vehicle Information
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Year
Make
Model
I.D. #
Miles Driven One
Way To Work
Miles Driven
Each Year
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Under 5,000
5,000-9,999
10,000-14,999
15,000-19,999
20,000-24,999
30,000-34,999
35,000-39,999
40,000-44,999
45,000-49,999
50,000+
Ownership
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Leased
Paid-Off
Financed
Violation Information
Last 3 Yrs (Minors)
Last 5 Yrs (Majors)
Driver 1
Driver 2
Driver 3
Driver 4
Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - Non Chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Accidents - Chargeable
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Major Violations - Drunk Driving,
Reckless, Hit & Run, etc.
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
None
1
2
3
4
Coverage Information
Bodily Injury
Property Damage
Personal Liability
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
5,000
10,000
25,000
50,000
100,000
Uninsured Motorist
No Coverage
15,000/30,000
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
No Coverage
3,500
Deductible Waiver
Medical Payment:
No Coverage
1,000
2,000
2,500
5,000
10,000
15,000
20,000
25,000
50,000
100,000
Deductible Information
Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
Comp (Theft)
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
Collision
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
No Coverage
250
500
1,000
1,500
2,000
Miscellaneous Information
Current Insurance Company:
Expiration Date:
Current Premium $:
Questions or Comments
to help the Agent:
