Automobile Insurance Application for California-Arlan Knutson Insurance Agency

Arlan Knutson Insurance Agency
Application for California Auto Insurance
Personal automobile coverage, multiple vehicle, multiple driver, etc.
Click on the Submit button at the bottom of the form to send to the Arlan Knutson Insurance Agency. You can also fill out and print this form; FAX to: 1-760-728-5029,
or mail to: 21160 Box Springs Rd #103, Moreno Valley CA 92557
If you are unsure of an answer, enter "Don't Know"

Applicant

Name

Residence Address

Mailing Address

City CA Zip -

Phone Fax Email

Do you currently have insurance? Yes No

If yes, who is the current company?

Expiration Date Years With Company

Driver Information

	Driver 1	Driver 2	Driver 3
Name
Date of Birth
Marital Status
Years Licensed
Student?
Driving Classes
Tickets*	0 1 2 3+	0 1 2 3+	0 1 2 3+
Accidents*	0 1 2 3+	0 1 2 3+	0 1 2 3+

*If you have had any tickets or accidents, in the last 3 years, you MUST provide your driver's license number and describe your tickets or accidents below.

Additional Driver Information

1 Way Distance to Work	Used for Business	Occupation
Driver 1 drives miles to work.	Yes No
Driver 2 drives miles to work.	Yes No
Driver 3 drives miles to work.	Yes No

Describe the details of tickets or accidents for each driver:

Vehicle Information. When listing vehicles, assume that Driver 1 primarily drives Vehicle 1 and Driver 2 primarily drives Vehicle 2, etc.

Vehicle	Year	Make	Model	Body Type (Select all that apply)
1				2 Dr 4Dr Pickup Van Wagon 4WD
2				2 Dr 4Dr Pickup Van Wagon 4WD
3				2 Dr 4Dr Pickup Van Wagon 4WD

Vehicle	Safety Features, Select all that apply.
1	1 Air Bag Dual Air bags Anti-Lock Brakes Passive Alarm Daytime Run Lights Auto Seat Belts
2	1 Air Bag Dual Air bags Anti-Lock Brakes Passive Alarm Daytime Run Lights Auto Seat Belts
3	1 Air Bag Dual Air bags Anti-Lock Brakes Passive Alarm Daytime Run Lights Auto Seat Belts

Insurance Coverage

Vehicle	VIN #	Garaging Zipcode	Vehicle Leased?	Comprehensive Deductible:	Collision Deductible:
1			Yes No	$100 $250 $500 $1000	$250 $500 $1000
2			Yes No	$100 $250 $500 $1000	$250 $500 $1000
3			Yes No	$100 $250 $500 $1000	$250 $500 $1000

Ever Filed For Bankruptcy?	Do you own your home?	Is Your Credit Rating:
Yes No	Yes No	Poor Fair Good Excellent
What other types of Insurance do you have?
Home Life Flood Boat Motorcycle Business Auto Umbrella Long Term Care Disability Business

Include Towing/Emergency Road Service in quote.
Include Rental Replacement in the quote.

Coverage

Liability Coverage	minimum	25/50	50/100	100/300	250/500
Property Damage	minimum	$10,000	$25,000	$50,000	$100,000
Uninsured Motorist	minimum	25/50	50/100	100/300	250/500
Auto Medical Payments	$1,000	$2,000	$5,000	$10,000	$25,000

Do you need an Umbrella policy to get higher than $500,000 limits.
We can do that for a very competitive price.
Questions? Call 800-542-9333