Please complete the form entirely as there are many required fields.  If already have automobile insurance, your current policy declaration page will have much of the needed information. Type "unsure" if you are unable to answer a question. All information entered in this form is held as strictly confidential by Pavese-McCormick Insurance Agency.

All items marked with in BLUE are required fields!
Contact Information
*Name
 *Street Address
*City
 State
*Zip Code
 County
*Daytime Phone
 Evening Phone
Fax
 *E-mail Address
*How You Found Us
 If you found us by some other means not listed to the left, please specify below
Insurance Policy Information
*Are you currently insured?
 CHECK ONE
Yes
No*		 *If No, give reason, i.e., First time insured, policy canceled 6 months ago, etc.
If yes, by what company?
Policy Expiration Date
Length of time
continuously insured
Driver Information
*Driver Name
*Date of
Birth
*Marital
Status
*Gender
*# Yrs 
Licensed
*# Tickets in
3.5 Years
*#Accidents in 3.5 Years
(regardless of fault)
1 M
F
2 M
F
3 M
F
4 M
F
Vehicle Information
Vehicle Model Year
Make
Model
Body Type (Check all that apply)
1
2 Dr 4 Dr Pickup Van Wagon 4WD
2
2 Dr 4 Dr Pickup Van Wagon 4WD
3
2 Dr 4 Dr Pickup Van Wagon 4WD
4
2 Dr 4 Dr Pickup Van Wagon 4WD
Vehicle
Vehicle ID #
Vehicle Leased?
Comprehensive Deductible
Collision Deductible
1
Yes No
2
Yes No
3
Yes No
4
Yes No
Safety Features (Select all that apply)
Vehicle 1 1 Air Bag 2 Air Bags Anti-Lock Brakes Passive Alarm Day Run Lights Auto Seat Belts
Vehicle 2 1 Air Bag 2 Air Bags Anti-Lock Brakes Passive Alarm Day Run Lights Auto Seat Belts
Vehicle 3 1 Air Bag 2 Air Bags Anti-Lock Brakes Passive Alarm Day Run Lights Auto Seat Belts
Vehicle 4 1 Air Bag 2 Air Bags Anti-Lock Brakes Passive Alarm Day Run Lights Auto Seat Belts
Additional Driver Information (Drivers' License # must be provided if any tickets or accidents)
Vehicle Driven & 1-Way Miles to Work
 Occupation Drivers License #
Social Security #
Driver 1 drives vehicle  , miles to work or school
Driver 2 drives vehicle  , miles to work or school
Driver 3 drives vehicle  , miles to work or school
Driver 4 drives vehicle  , miles to work or school
Please Detail any Tickets and/or Accidents in the Space Below

(Please indicate Driver and Vehicles # as you referenced above for each incident.)
Liability Coverages
Liability Coverage Property Damage Uninsured Motorists Personal Injury Protection
Required Underwriting Information
Ever Filed for Bankruptcy?
Do you own your home?
Is Your Credit Rating:
Yes No
Yes No
 Poor 
Fair
Good
Excellent
Please select other types of Insurance you currently have (whether it be with Pavese-McCormick or Other Insurance Agency):
Long-Term Care
Life Insurance
Homeowners
Disability Insurance
Annuities
Health Insurance
Please provide any additional information or comments below.

 

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