HUH Automobile Insurance Pre-Application

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Auto Coverage FAQ

Personal Automobile Pre-Application

Verification Approval You may either complete the form online below, or click here to download a printable form in Adobe pdf format that you can complete and fax to us. To prepare your quote, we will review your driving records and insurance claims for the past three years. Insurance companies may also require that we confirm your financial stability, but we do not see your credit history. If you agree to these procedures, please check AGREE and add your name. If you indicate DO NOT AGREE, sorry, we cannot provide you an accurate quote at this time. I AGREE I DO NOT AGREE Name
How many drivers in your household?
How many cars in your household?
*Vehicle #1:
	Model	Make	Year
	Body Style
	VIN#
	Name of primary driver of vehicle #1
	Date of Birth		Male female
	SS#
	Driver's license#		State:
	Date when current drivers license was obtained
	Marital Status
*Vehicle #2:
	Model	Make	Year
	Body Style
	VIN#
	Name of primary driver of vehicle #2
	Date of Birth		Male female
	SS#
	Driver's license#		State:
	Date when current drivers license was obtained
	Marital Status
*Vehicle #3:
	Model	Make	Year
	Body Style
	VIN#
	Name of primary driver of vehicle #3
	Date of Birth		Male female
	SS#
	Driver's license#		State:
	Date when current drivers license was obtained
	Marital Status
*Vehicle #4:
	Model	Make	Year
	Body Style
	VIN#
	Name of primary driver of vehicle #4
	Date of Birth		Male female
	SS#
	Driver's license#		State:
	Date when current drivers license was obtained
	Marital Status
*Vehicle #5:
	Model	Make	Year
	Body Style
	VIN#
	Name of primary driver of vehicle #5
	Date of Birth		Male female
	SS#
	Driver's license#		State:
	Date when current drivers license was obtained
	Marital Status
Indicate if any drivers 21 or younger have drivers training credit or if any full time students have a "B" average (3.0)or better:
PLEASE INDICATE WHICH VEHICLES ARE EQUIPPED WITH THE FOLLOWING DEVICES:
VEHICLE #1
	AIRBAG	ANTI-LOCK BRAKES (ABS)
	ANTI-THEFT ALARM	FUEL IGNITION CUT -OFF
		MOTORIZED SEAT BELTS
VEHICLE #2
	AIRBAG	ANTI-LOCK BRAKES (ABS)
	ANTI-THEFT ALARM	FUEL.IGNITION CUT -OFF
		MOTORIZED SEAT BELTS
VEHICLE #3
	AIRBAG	ANTI-LOCK BRAKES (ABS)
	ANTI-THEFT ALARM	FUEL.IGNITION CUT -OFF
		MOTORIZED SEAT BELTS
VEHICLE #4
	AIRBAG	ANTI-LOCK BRAKES (ABS)
	ANTI-THEFT ALARM	FUEL.IGNITION CUT -OFF
		MOTORIZED SEAT BELTS
VEHICLE #5
	AIRBAG	ANTI-LOCK BRAKES (ABS)
	ANTI-THEFT ALARM	FUEL.IGNITION CUT -OFF
		MOTORIZED SEAT BELTS
Please indicate the primary use for each vehicle
Vehicle #1
	Driven to work or school	miles one way
	Business use	avg. weekly mileage
	shopping/errands	avg. weekly mileage
Vehicle #2
	Driven to work or school	miles one way
	Business use	avg. weekly mileage
	shopping/errands	avg. weekly mileage
Vehicle #3
	Driven to work or school	miles one way
	Business use	avg. weekly mileage
	shopping/errands	avg. weekly mileage
Vehicle #4
	Driven to work or school	miles one way
	Business use	avg. weekly mileage
	shopping/errands	avg. weekly mileage
Vehicle #5
	Driven to work or school	miles one way
	Business use	avg. weekly mileage
	shopping/errands	avg. weekly mileage
Average mileage is 12,000-15,000 per year. Please indicate if any of the vehicles are driven more than than that, or less than 5,000 miles per year.
Do any of the vehicles have special wheels, customized paints or lights or other decor, car phones or other non-stock equipment? yes No
	If yes, please describe:
Have any drivers ever had their license revoked or suspended?			Yes No
	If yes, please describe:
Has your automobile insurance ever been cancelled or not renewed for any reason OTHER THAN non-payment?			Yes No
	If yes, please describe:
Have you ever filed for bankruptcy			Yes No
	If Yes, what year

YOUR CURRENT COVERAGE
Your Current Insurance Company
Since (Year)
Expiration Date of Current Policy
Personal Liability Limit/Bodily Injury and Property Damage:		$
Personal Injury Protection (PIP):		$
Uninsured/Underinsured Motorists Bodily Injury:		$
Property Damage Deductible:
	For Collision	$
	For Comprehensive	$
	Towing	$
	Rental Reimbursement (limit per day)	$
Zip Code Where Cars Are Kept
Your Home Phone		( )
Work Phone		( ) ext.