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Applicant Information - Step 1 of 6

APPLICANT INFO:

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Gender *

Male
Female

Occupation *

Education *

Marital Status *

Driver's License Number *

Driver's License State *

Preferred Language *

English
Spanish
Chinese (Mandarin)

Is there a co-applicant? *

Yes
No

SPO-- USE / DOMESTIC PARTNER INFO:

CO-APPLICANT INFO:

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Gender *

Male
Female

Occupation *

Education *

Relationship to Applicant *

Driver's License Number *

Driver's License State *

CONTACT INFO:

Phone *

Email *

Where do you reside? *

Address Line 1

City

State

Zip Code

Do you own or rent your home? *

Own
Rent

Have you lived here for at least a year? *

Yes
No

Where did you reside previously? *

Address Line 1

City

State

Zip Code

Would you like to receive additional discounts by bundling your auto and home? *

Yes, I'd like additional discounts
No thanks

Are you currently insured? *

Yes
No

Who is your current insurance carrier? *

Carrier Name: *

What are your current liability limits? *

How long have you been insured with your current carrier? *

How long have you maintained continuous insurance with no lapse? *

Are there additional drivers in your home? *

Yes
No

How many additional Drivers? *

ADDITIONAL DRIVER #1:

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Gender *

Male
Female

Relationship to Applicant *

Driver's License Number *

Driver's License State *

ADDITIONAL DRIVER #2:

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Gender *

Male
Female

Relationship to Applicant *

Driver's License Number *

Driver's License State *

ADDITIONAL DRIVER #3:

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Gender *

Male
Female

Relationship to Applicant *

Driver's License Number *

Driver's License State *

ADDITIONAL DRIVER #4:

Name *

First

Last

Date of Birth (MM/DD/YYYY) *

Gender *

Male
Female

Relationship to Applicant *

Driver's License Number *

Driver's License State *

How many vehicles do you have? *

Do you have the VIN for each vehicle? *

Yes
No

VEHICLE #1

Year *

Make (eg Ford) *

Model (eg Mustang) *

VIN *

Do you need full coverage on this vehicle? *

Yes
No

VEHICLE #2

Year *

Make (eg Ford) *

Model (eg Mustang) *

VIN *

Do you need full coverage on this vehicle? *

Yes
No

VEHICLE #3

Year *

Make (eg Ford) *

Model (eg Mustang) *

VIN *

Do you need full coverage on this vehicle? *

Yes
No

VEHICLE #4

Year *

Make (eg Ford) *

Model (eg Mustang) *

VIN *

Do you need full coverage on this vehicle? *

Yes
No

VEHICLE #5

Year *

Make (eg Ford) *

Model (eg Mustang) *

VIN *

Do you need full coverage on this vehicle? *

Yes
No

VEHICLE #6

Year *

Make (eg Ford) *

Model (eg Mustang) *

VIN *

Do you need full coverage on this vehicle? *

Yes
No

Have you or a member of your household had any of the following in the last 5 years? *

At-Fault Accident
Not-At-Fault Accident
Moving Violation (speeding, stop sign, etc)
DUI (driving under the influence)
Wreckless Driving / Hit-and-Run
None

Number of at-fault accidents in the last 5 years: *

Number of not-at-fault accidents in the last 5 years: *

Number of moving violations in the last 5 years: *

YOU'RE ALMOST DONE!

Great job! you've reached the last step of your application. Now is your chance to give us any last-minute details that will help us provide the best quote for you. Are there additional drivers/vehicles? Are you not sure if you answered a question correctly? Let us know!

Additional Remarks:

Name

2009 Summer St, 3rd Fl
Stamford, CT 06905

203-883-6290
hello@zuritainsurance.com

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