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Online Auto Insurance Review

PLEASE TAKE THE TIME TO FULLY COMPLETE THIS FORM. We will use the confidential facts that you provide to better protect your home, personal property, and personal liability.
Questions? Call Jeanne Way at 231-547-4062 or 1-800-748-0414, or email Jeanne.

People

How many licensed drivers are in your household?

Please list each person who lives in your household, including children:

#1 Name:	Date of birth:
#2 Name:	Date of birth:
#3 Name:	Date of birth:
#4 Name:	Date of birth:
#5 Name:	Date of birth:
#6 Name:	Date of birth:
#7 Name:	Date of birth:

Feel free to enter any additional information or comments in the space below:

Vehicles

How many vehicles do you (or your spouse) own or lease?

Please list each of these vehicles below and advise how they currently are used:

#1 Year:	Make:	Model:	Use:
#2 Year:	Make:	Model:	Use:
#3 Year:	Make:	Model:	Use:
#4 Year:	Make:	Model:	Use:
#5 Year:	Make:	Model:	Use:

Are any of the above vehicles NOT owned by you?
No Yes -- These are the non-owned vehicles: 1 2 3 4 5

Have any of the above vehicles you own or lease been customized in any way?
No Yes, here's how:

Vehicle #: has been customized or modified as follows:

Vehicle #: has been customized or modified as follows:

Have any of the vehicles you own or lease been refinanced or paid off?
No Yes, here's how:

Vehicle #: has been Paid-off Refinanced through
Vehicle #: has been Paid-off Refinanced through

Feel free to enter any additional information or comments in the space below:

Potential Discounts

Check off the auto insurance discounts to which you believe you're entitled:

	Passive restraint system - Requires both airbags and automatic seatbelts.
		Anti-Lock brakes - Requires automatic factory-installed anti-lock braking system: ABS.
		Daytime running lights - Requires automatic factory-installed head lights that are on continuously during the day.
		Defensive driver course - For all drivers who have completed an approved course.
		Age of driver credit - For mature drivers over the age of 50.
		Good student credit - Applies when youthful drivers maintain a 3.0 or B average.
		Resident student - Applies when student is under 21 and over 100 miles away.
	Loss-free record - Applies when you've gone without an auto claim for 3 consecutive years.
		Multi-car discount - When there are two or more cars insured on the same policy.
		Home & car credit - Discounts off each policy when both are with the same company.
Anti-theft devices - Discounts vary by type of device installed. Which do you have?
		Electronic tracking device (such as "LoJack")
		Passive theft disabling device
		Alarms + an active anti-theft disabling device
		Window etching vehicle ID system

Enter any comments concerning the above discounts in the space below:

Extra Protection

Check off the extra coverages on which you would like information:

	Car rental coverage - in case of an accident, stolen car, or other insured event.
	Extra towing & labor coverage - in case of a breakdown, flat tire, etc.
	Higher limits of liability protection - in case you're involved in a serious accident.
	Higher limits of no-fault protection - in case you're injured in an auto accident.
	Special coverage for your auto sound system.
	Homeowners, Condo-unit, or renters insurance
	$1,000,000 Umbrella Policy (or higher)
	Business insurance
	Identity-Theft Insurance
	Low-cost Term Life Insurance
	Retirement Planning / College Funds
	Health insurance / Personal income protection
	Motorcycle Insurance / RV / snowmobile / golf cart
	Boat Insurance
	Flood Insurance
	College Savings Plans
	Personal Income Protection
	Long-Term Care

I am interested in information on the above protection. Please contact me by ...
Email Regular Mail Phone [Enter numbers below]

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Thank you for taking the time to complete this online review. Its purpose is to assist us in determining if your homeowners insurance needs some tuning to match up with the current conditions in your home and personal life. We promise to get back to you shortly!

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Bingham Insurance Services • 207 Ferry Avenue, P.O. Box 318 • Charlevoix, Michigan 49720
Need a map? • Ph: 231-547-4062 or 1-800-748-0414 • Fax: 231-547-0655 • Email Us