Auto Application Form

1501 Westcliff Dr. Suite 301
Newport Beach, CA. 92660
Tel: (877) 700- NEWS
Fax: (949) 554-0250
Email: Info@newsinsurance.com
Web: www.newsinsurance.com
Section 1 - PERSONAL AUTO
Quote Date : - - (mm/dd/yyyy)
First Name :
Last Name :
Location :
City : State : Zip Code :
Home No. :
Businness No. : * Ext.
E-Mail. :
Current Policy Expiration Date :
Social Security No. :
Location of Garage :
(if diff. from Above)
City : State : Zip Code :
Section 2 - VEHICLE DESCRIPTION/INCLUDING RV'S
Year of Vehicle 1 : Make : Model :
Body Type : VIN # : Registered State :
Registered Date : Current Vehicle Mileage : Annual Mileage :
     
Year of Vehicle 2 : Make : Model :
Body Type : VIN # : Registered State :
Registered Date : Current Vehicle Mileage : Annual Mileage :
     
Year of Vehicle 3. : Make : Model :
Body Type : VIN # : Registered State :
Registered Date : Current Vehicle Mileage : Annual Mileage :
     
Year of Vehicle 4 : Make : Model :
Body Type : VIN # : Registered State :
Registered Date : Current Vehicle Mileage : Annual Mileage :
 
 
Section 3 - COVERAGE / PREMIUMS
Coverages
Limits Of Liability
 
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4
Bodily Injury Liability
Property Damage Liability
Medical Payments
Uninsured Motorist
Uninsured Motorist Property Damage
Comprehensive Deductible
Collision Deductible
Waiver of Collision Deductible
Towing and Labor
Trans Exp/Rental Re-imbursement
Death Indemnity Insurance
None Manufacture Equipment $ $ $
Section 4 - RESIDENT & DRIVER INFORMATION
Driver 1 Name : Relation to Insured Drivers License Marital Status  
Rel. to Appl. D.O.B. Occupation # of Yrs. Licensed in U.S. Good Student
yrs.
         
Driver 2 Name : Relation to Insured Drivers License Marital Status  
Rel. to Appl. D.O.B. Occupation # of Yrs. Licensed in U.S. Good Student
yrs.
         
Driver 3 Name : Relation to Insured Drivers License Marital Status  
Rel. to Appl. D.O.B. Occupation # of Yrs. Licensed in U.S. Good Student
yrs.
         
Driver 4 Name : Relation to Insured Drivers License Marital Status  
Rel. to Appl. D.O.B. Occupation # of Yrs. Licensed in U.S. Good Student
yrs.
         
 
Section 5 - ACCIDENT/CONVICTIONS
Has any driver shown above had an accident, regardless of fault, or been convicted of a moving violation with the last 3 years? Yes
Driver # Date Of Accident/Conviction : Description of Accident/Conviction :
Place of Accident/Conviction :
 Bodily Injury or Death? Amount of Property Damage :
     
Driver # Date Of Accident/Conviction : Description of Accident/Conviction :
Place of Accident/Conviction :
 Bodily Injury or Death? Amount of Property Damage :
     
Driver # Date Of Accident/Conviction : Description of Accident/Conviction :
Place of Accident/Conviction :
 Bodily Injury or Death? Amount of Property Damage :
     
Driver # Date Of Accident/Conviction : Description of Accident/Conviction :
Place of Accident/Conviction :
 Bodily Injury or Death? Amount of Property Damage :
Sales Agent:  
NEWS Insurance Services Inc © 2006 All rights reserved