Auto

Thank you for the opportunity to quote your business. Please completely fill out the form below and submit it to us to receive a no-obligation quote. Or, if you prefer, you can download the questionnaire as a PDF to print out and fill in and then bring it in or fax it to us. Three Rivers Agency, Inc values your privacy and will not sell, disclose or share your information with other parties without your consent.

Please give us a call at (208) 642-9311 if you have any questions about the questionnaire.
Rene Hall
Personal Lines CSR • Payette Branch
 
Download the Auto Quote questionnaire by clicking here.
YOUR INFORMATION
Name:
Date of Birth:
(00/00/00)
Social Security Number:
Address:
City:
State:
Zip/Postal Code:
Phone:
Email Address:
Other members of the household:
Name: Date of Birth:
(00/00/00)
Drivers License #: Relations:
Name: Date of Birth:
(00/00/00)
Drivers License #: Relations:
Name: Date of Birth:
(00/00/00)
Drivers License #: Relations:
Name: Date of Birth:
(00/00/00)
Drivers License #: Relations:
Your occupation:
Miles to work:
Years at present occupation: (you)    (spouse)
Any children who have a
3.0 grade point average?
(who and current average)		 Yes    No
Any children in college?
(who and where are they
and do they have a car)		 Yes    No
Years at present location:
(if less than 3, list prior address)
VIOLATIONS/CLAIMS
Has any driver been in an accident, had a claim or received a citation in the past three years?
(claims include windshield repairs or replacements)
Driver:
Date:
Type:
Brief Summary:
Driver:
Date:
Type:
Brief Summary:
Driver:
Date:
Type:
Brief Summary:
Driver:
Date:
Type:
Brief Summary:
AUTOMOBILES
Number of vehicles in the household (please list all)
Year: Make:
Model: Driver:
Lein Holder? Name:
Year: Make:
Model: Driver:
Lein Holder? Name:
Year: Make:
Model: Driver:
Lein Holder? Name:
Year: Make:
Model: Driver:
Lein Holder? Name:
Year: Make:
Model: Driver:
Lein Holder? Name:
COVERAGES DESIRED
Liability limits: (i.e. $100,000 - $300,000 - $500,000)
Uninsured/Underinsured limits: (i.e. $100,000 - $300,000 - $500,000)
Medical/PIP limits: (i.e. $5,000 - $10,000 - $25,000)
Comprehensive deductible: (i.e. $250 - $500 - $1,000)
Which Cars?
Collision deductible: (i.e. $250 - $500 - $1,000)
Which Cars?
Towing? Yes   No
Rental car coverage quoted? Yes   No
Rental/Towing on which cars:
Any exhisting damage
to any of the vehicles:		 Yes   No
Please describe
UNDERWRITING
Are any of the vehicles used by
drivers not in the household?		 Yes   No
if so, please describe the relationship, include driving information
Who is your present auto carrier?
The policy number:
How long have you been
with your carrier?
Have you had continuous
coverage for one year?		 Yes   No
If you do not have current coverage, how long has it been lapsed?
Are all drivers citizens of the U.S. & or resided in the U.S. for at least 3 years? Yes   No
Has anyone in the household been arrested or detained by the police or juvenile authorities for any reason in the past 5 years? Yes   No
Type of residence:
If insured is divorced/separated,
how long?
Is divorce final? Yes   No
Are any of the vehicles
used commercially?
(contractors, real estate, etc)		 Yes   No
Are all of the vehicles registered
to the applicant? 		Yes   No
If no, please describe
If insured is over 55, have they
taken any drivers safety courses:
(please describe)
AAA membership? Yes   No
Garaging address same as mailing? Yes   No
By filling out this form, the applicant authorizes and grants permission to Three Rivers Agency, Inc to make inquiry of the applicant's previous insurance carriers and to obtain a credit report. Applicant understands and agrees that information obtained from these sources may be utilized in construction of applicants rate and quote. Applicant declares all statements herein are true and correct to the best of his/her knowledge:
Fill in full legal name:
Date:
Comments:
Three Rivers Insurance Address