New Business Questionnaire - The Seltzer Group

Auto Drivers Information - Driver 1

We will provide the ability to enter up to 4 drivers in the same household. In the event there are more drivers, please notify us when we review your application.

Name:

First Last

Date of birth:

Driver's License Number:

Date Licensed:

Marital Status:

Sex:

Male
Female

Accidents or violations (please describe below):

Please select any or all that apply:

Student living more than 100 miles away
Good Student
Driver Training

Accident prevention course?

Yes
No

Date completed:

Highest level of education:

Do you do any ride-sharing (Uber, Lyft, etc.) or other delivery services?*

Yes
No

Please list any additional comments or concerns you have regarding the above questions, here:

Are there any more drivers in the household?*

Yes
No

Auto Drivers Information - Driver 2

Name:

First Last

Date of birth:

Driver's License Number:

Date Licensed:

Marital Status:

Sex:

Male
Female

Accidents or violations (please describe below):

Please select any or all that apply:

Student living more than 100 miles away
Good Student
Driver Training

Accident prevention course?

Yes
No

Date completed:

Does this driver do any ride-sharing (Uber, Lyft, etc.) or other delivery services?*

Yes
No

Please list any additional comments or concerns you have regarding the above questions, here:

Are there any more drivers in the household?*

Yes
No

Auto Drivers Information - Driver 3

Name:

First Last

Date of birth:

Driver's License Number:

Date Licensed:

Marital Status:

Sex:

Male
Female

Accidents or violations (please describe below):

Please select any or all that apply:

Student living more than 100 miles away
Good Student
Driver Training

Accident prevention course?

Yes
No

Date completed:

Does this driver do any ride-sharing (Uber, Lyft, etc.) or other delivery services?*

Yes
No

Please list any additional comments or concerns you have regarding the above questions, here:

Are there any more drivers in the household?*

Yes
No

Auto Drivers Information - Driver 4

Name:

First Last

Date of birth:

Driver's License Number:

Date Licensed:

Marital Status:

Sex:

Male
Female

Accidents or violations (please describe below):

Please select any or all that apply:

Student living more than 100 miles away
Good Student
Driver Training

Accident prevention course?

Yes
No

Date completed:

Does this driver do any ride-sharing (Uber, Lyft, etc.) or other delivery services?*

Yes
No

Please list any additional comments or concerns you have regarding the above questions, here:

Additional Details

Do you have access to a company vehicle on a full-time basis?*

Yes
No

Please provide vehicle details:

Are there any additional drivers in the household with their own insurance or vehicle? (If yes, please describe below.)*

Yes
No

Please provide additional drivers names, dates of birth and vehicle information:

Please list any additional comments or concerns you have regarding the above questions, here:

NEW Free Quote Questionnaire

Step 1 of 13

Instructions

Insured's Information

Insurance Information

Home Underwriting Questions

Home Property and Construction

Wall Finish Types

Flooring Types

Do you have any of the following in your home?

Additional property questions:

Auto Drivers Information - Driver 1

Auto Drivers Information - Driver 2

Auto Drivers Information - Driver 3

Auto Drivers Information - Driver 4

Additional Details

Auto Vehicle Information - Vehicle 1

Auto Vehicle Information - Vehicle 2

Auto Vehicle Information - Vehicle 3

Auto Vehicle Information - Vehicle 4

Current Auto Coverage Information

First Party Benefits

Uninsured/Underinsured Motorists

Physical Damage Coverage

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Personal Umbrella

Life Questions

Life Questions for Spouse or Significant Other

Remarks and Comments

Our Approach

Our Mission

Quick Links

*NEW* Free Quote Questionnaire

Step 1 of 13

Instructions

Insured's Information

Insurance Information

Home Underwriting Questions

Home Property and Construction

Wall Finish Types

Flooring Types

Do you have any of the following in your home?

Additional property questions:

Auto Drivers Information - Driver 1

Auto Drivers Information - Driver 2

Auto Drivers Information - Driver 3

Auto Drivers Information - Driver 4

Additional Details

Auto Vehicle Information - Vehicle 1

Auto Vehicle Information - Vehicle 2

Auto Vehicle Information - Vehicle 3

Auto Vehicle Information - Vehicle 4

Current Auto Coverage Information

First Party Benefits

Uninsured/Underinsured Motorists

Physical Damage Coverage

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Personal Umbrella

Life Questions

Life Questions for Spouse or Significant Other

Remarks and Comments

Our Approach

Our Mission

Quick Links

NEW Free Quote Questionnaire