Contact
Information
|
|
* Todays
Date:
(mm/dd/yyyy)
|
|
|
*
First Name:
|
|
*
Last
Name:
|
|
|
*
Street Address:
|
|
*
City:
|
|
|
*
State:
|
|
*
Zip:
|
|
|
*
County:
|
|
*
Home
Phone:
">(999-999-9999)
|
|
|
*
Work
Phone:
(999-999-9999)
|
|
*
Email:
|
|
|
*
What
is the best time
to contact you?:
|
|
*
Best
way to contact
you?:
|
Email
Phone
Work Phone
|
|
* Are
you currently
(or have you ever been) a Clark customer?
|
Yes No
|
*
How did you hear
about Clark?
|
Other: Please Specify
|
Driver
Information
|
|
*
Name:
|
|
*
Date
of Birth:
(mm/dd/yyyy)
|
|
|
*
Gender:
|
|
*
Marital Status:
|
|
|
*
Residence:
|
|
*
Relationship to
Driver#1:
|
|
|
Social
Security Number:
(e.g. 555-55-5555)
|
|
*
Drivers License
Number:
|
|
|
* At
what age did this
driver first receive their license?:
|
|
*
Has
this driver been
a U.S. or Canadian resident for the past 12 months?:
|
Yes No
|
|
*
Has
this driver
completed Behind-the-Wheel in the last 5 years?:
|
Yes No
|
* Is
this driver a
full-time student with GPA of 3.0 or above?:
|
Yes No
|
|
* In
the past 5 years,
has the driver's license been suspended or revoked?:
|
Yes No
|
*
Does
the driver
require an SR-22 or Financial Responsibility Statement?:
|
Yes No
|
|
* In
which state is
this driver currently licensed?:
|
|
*
What
is the driver's
highest education level?:
|
|
|
*
Past
or Present
Military Experience?:
|
|
*
What
is your
occupation?:
|
|
|
*
How
long have you
been with your occupation?:
|
|
* In
the past 5 years
have you filed for bankruptcy?:
|
Yes No
|
|
* In
the past 5 years
have you had any repossessions, charge offs, or collections?:
|
Yes No
|
*
How
would you
describe your credit rating?:
|
Poor
Good
Excellent
Unsure
|
Incident
Information
|
Incident 1:
Date of Incident:
(mm/yyyy)
|
|
Incident 2:
Date of Incident:
(mm/yyyy)
|
|
Incident 3:
Date of Incident:
(mm/yyyy)
|
|
Incident 4:
Date of Incident:
(mm/yyyy)
|
|
Vehicle
Information
|
|
*
Year:
|
|
*
Make:
|
|
|
*
Model:
|
|
*
VIN
#:
|
|
|
*
Zip
Code where
vehicle is garaged most:
|
|
*
Who
is the primary
driver of this vehicle?:
|
|
|
* Is
the vehicle
primarily driven for commuting, business, or pleasure?:
|
|
* If
used for commuting
or business - average number of days per week used?:
(enter "0" if not applicable)
|
|
|
* If
vehicle is used
for commuting - what is the average one-way mileage?:
(enter "0" if not applicable)
|
|
*Approximately
how many
miles is the vehicle driven in a year?:
(average american drivers 12,000 per year)
|
|
|
*
Current Carrier:
|
|
*
Current Policy
Expiration Date:
(mm/dd/yyyy)
|
|
|
Comprehensive
and Collision deductible: Select the amount you are willing to pay in
the event of a claim. The higher the deductible the lower the cost for
the coverage. Finance companies require you carry this coverage if you
are either purchasing or leasing a vehicle.
|
*
Comprehensive:
*
Collision:
|
*
Towing Labor:
|
Yes No
|
|
*
Rental Reimbursement:
|
Yes No
|
* Is
this vehicle
leased?:
|
Yes No
|
| |
|