car.html

Fair Oaks Insurance Agency
lic #0429039
On line auto application
This is an application only and not a binder (see disclaimer)
Name

Street

City

State Zip Code

Phone

SS No. Date of Birth Occupation
Driver information; all drivers must be listed
driver1 dob Lic# occ
driver2 dob Lic# occrelationship
driver3 dob Lic# occrelationship
driver4 dob Lic# occrelationship
Has any driver been cited for a minor moving violation, or been involved in an accident, regardless of fault, in the last 3 years? yes no
Has any driver been cited for a major moveing violation (driveing under the influence, hit and run etc.) in the past 5 years. yes no If yes to either question complete the next section if no then skip to auto information.
dr# date type accident yes no- at faultyes no
dr# date type accident yes no- at faultyes no
dr# date type accident yes no- at faultyes no
dr# date type accident yes no- at faultyes no
Is a financial responcibility fileing required for any driver?yes
If yes which driver.
Auto Information; all autos must be listed.
Auto1
yr make model id# annual miles
Dr# Comp yes no Collision yes no

Auto 2
yr make model id# annual miles
Dr# Comp yes no Collision yes no

Auto 3
yr make model id# annual miles
Dr# Comp yes no Collision yes no

Auto 4
yr make model id# annual miles
Dr# Comp yes no Collision yes no

Do you have insurance now? YesNo


If yes which company
policy #

expiration date

How long have you been insured 0-1 yrs1-3 yrs3-5 yrsover 5
Select Coverage's
Bodily injury liability
$15/30,000 $25/50,000 $50/100,000 $100/300,000
Higher limits available upon request.
Uninsured Motorists
Coverage's will be equal to the bodily injury liability limits selected. They may be adjusted later if needed.
Medical Payments: $1000 $2000 $3000 $4000 $5000
Medical payments will apply to all autos.
Comprehensive deductibles: $100 $250 $500 $1000
deductibles will be the same on all autos selected.
Collision Deductibles: $250 $500 $1000
Collision deductibles will be the same on all autos selected.

A quotation will be provided, and a company selected based on the information provided. We will start processing as soon as we receive your request. If for some reason this does not appear as form on your system then e-mail or fax us and we will contact you to complete an application.
DISCLAIMER: No coverage is provided until an application signed by the applicant, and other necessary information and required payment are received, and the application is accepted by the insurance carrier to whom was submitted.

All applications are subject to further underwriting, which may or may not effect the rate. by the insurance company to whom it was submitted. We will attempt to notify you of any rate increases, when they become known to us.

You may contact us as follows:

TOLL FREE 800-840-8650

PHO (559) 562-4019 (24 hr. a day 7 days a week)

FAX (559) 562-9389 (8:00 am to 5:00pm Mon-Fri)

FAX (559) 734-3865 (24 hr. a day 7 days a week)

E-MAIL jmohnike@psnw.com

Back to personal lines, home page or go to homeowners
 Boy am I glad this parts over.
Last Updated 12/7/98 jmohnike@psnw.com