Many auto insurance companies will offer new/additional discounts in 2009. Please complete this form, and return it to our office so we may confirm you are receiving all of your eligible discounts.

If different from mailing address, please explain:

How would you prefer that we contact you and at what general time?

1. Do any of your vehicles have anti-theft device? If YES, which vehicle(s) and describe devices(s)?

2. Low Mileage Discount: to determine your eligibility, please list your current odometer reading by vehicle.

3. Are any of the above vehicles a hybrid? If so, which vehicle(s)?

4. Are any of your vehicles used on a farm? If so, which vehicle(s)?

6. If any listed drivers have their own auto policy or are listed on another policy please list the driver’s name, insurance company, policy # and effective date of other policy(ies):

7. Do you want to exclude any driver(s) from a vehicle? If YES, list driver and vehicle(s) to which the exclusion should apply:

8. Have any drivers attended a driver education course? If YES, which driver(s)?

(Also attach or send copy of Driver’s Ed Certificate)

9. Have any listed drivers attended an Advanced Driver Training Course? If YES, list driver(s).

(Also attach or send copy of Course Certificate)

10. Are any of the listed drivers currently attending college? If YES, list driver(s).

10A. Is the vehicle taken to college with them? If YES, which vehicle?

10B. Where is the college located?

11. Are any listed drivers employed by an educational institution? If YES, which driver(s)?
Which educational institution?

12. Do any young drivers qualify for a Good Student Discount? To qualify, a student must be on the dean’s list, honor roll, have a Grade B or better average in all subjects, or must be in the upper 20% of his/her class. If YES, which driver(s)?

13. Many companies now offer Account Discounts. Please provide a copy of the declaration page(s) for the following policies if they are not currently written with Eldredge & Lumpkin:
Home:
Umbrella:
Boat:
Other (describe):

14. Do you belong to any motor clubs (i.e. AAA or other)? If YES, please list name of club, your member ID number and the date your membership began:

15. Do any listed drivers use public transit to commute to/from work? If YES, please describe:

If we have any questions concerning your responses to this questionnaire, what is the best way to contact you and at what general time?

Many companies offer enhanced coverage under the new “managed competition” rules. We will advise you of the available enhancements once a review of your individual profile is completed, based upon the information you have provided to us in this questionnaire as well as the information we have in your file.

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE. IT WILL HELP US TO OFFER YOU THE BEST COMBINATION OF PRODUCT AND PRICE TO MEET YOUR INDIVIDUAL AUTO INSURANCE NEEDS.

Please print and mail completed questionnaire to:

Eldredge & Lumpkin Insurance
697 Main St., Chatham, MA 02633

... or submit questionnaire by e-mail: