Auto Risk Reduction Questionnaire

Insured Information
Name *
Address
City
Cell Phone
Cell Phone #2
Phone
Business Phone
Email
Vehicles:
I have paid off a loan for a vehicle(s) in the past year. (please forward a copy of your title) Yes  No
Do you have Non-Factory installed equipment? Rims, stereo, plow, tv/dvd, etc are not covered Yes  No
Please enter the value of custom equipment if you would like a quote.
I use my vehicle in business, other than commuting or have a company vehicle. If Yes, please explain. Yes  No
My vehicle(s) is/are owned by a trust * Yes  No
Do you routinely use vehicles you do not own? If Yes, please explain. * Yes  No
I have the following motorized vehicles. (please check all that apply): Motorcycle  Moped  ATV  Snowmobiels  Camper  Trailer
Antique Auto(s) - We represent Hagerty Insurance! Yes  No
Drivers
I have a teen driver who was recently licensed or will be licensed in the next year. * Yes  No
I have a child or other driver who is listed on my policy but no longer lives in our household or is a regular operator. * Yes  No
Other Drivers
Please provide the names and birthdates of any other residents in your household licensed to drive OR Regular operators NOT currently listed on your policy.
  Name Date of Birth Drivers License Number
1
2
3
Discounts
Discounts
I carpool or drive to work an average of less than 3 days per week. * Yes  No
I have a child who is licensed and whose grade average is better than 3.0. If yes please forward a copy of the school transcript. Yes  No
I have a child who is away at college. Yes  No
My child away at school has a vehicle with them. Yes  No  Not Applicable
I have completed an “Advanced Safe Driver Course” within the past 2 years. If Yes please submit Certificate. Yes  No
Value For Investment
Value For Investment
I have AAA or other auto club membership. If yes please submit copy of your membership card. Yes  No
I would consider increasing my deductibles to save money on my policy. * Yes  No
Am I maximizing my SAVINGS on ALL of my insurance? I own a home, condo or rent an apartment that is not insured with Babineau Ins. * Yes  No
I’m interested in knowing the cost of increased liability and uninsured/underinsured motorist protection – We recommend a MINIMUM of $250,000 per person. * Yes  No
If you don’t already have “Rental Car Coverage”, would you like to have a rental car provided for you for about a dollar a week if you have an accident? * Yes  No
If you do not have an auto club membership, would you like to be reimbursed up to $100 if you have to have your car towed? * Yes  No
I would like a quote for a $1,000,000 Umbrella Liability Policy. Yes  No
I would like to talk with an agent to review my current coverages. Please contact me by : Mail  Phone  E-Mail
NOTES
Please indicate any questions or comments you may have.
* = Required Field