Mid-Michigan Insurance Agency of Mt. Pleasant, Inc.

Personal Information

Insured's Name:

Insured's Phone:

License Number:

Date of Birth:

Occupation:

Car Driven:

Driving Record (or claims):

Driver # 2's Name:

License Number:

Date of Birth:

Occupation:

Car Driven:

Driving Record (or claims):

Other household members:

Address:

Mailing Address, if different:

If less than 1 year at current address:

Vehicle Information

List only the vehicles you want insured:

Year Make/Model Vehicle ID #

Vehicle 1:

Vehicle 2:

Primary Use Miles Driven One Way Leinholder

Vehicle 1:

Vehicle 2:

Coverage

Vehicle 1: Comprehensive Collision Towing Trans Exp. PLPD

Vehicle 2: Comprehensive Collision Towing Trans Exp. PLPD


Does anyone have health insurance (that covers auto accidents?)	yes no
If there prior Insurance - list company:
Expiration Date:
Did you just purchase the vehicle?	yes no
Residence:	Owned Rented Other
Insurance for residence, list company:
Are all vehicles titled to the insured? (They must be unless married)	yes no
Member of a Credit Union or Alumni Group? (please list group)