Herbert M. Sheaner, Jr. 
Insurance Agency

Tell us about you.

*First name
*Last name
Street address
Address (cont.)
*City
State
*Zip code
*County
Occupation
Work phone
Home phone
Fax
*Email
*Preferred means of contact	(choose one) Email Work phone Home phone Fax Mail
Social Security Number	A CLUE report will be requested to determine the best pricing available.  The CLUE is based on information from your credit history and 3 year loss experience.
*Clear credit history	(choose one) Yes No

Tell us about your vehicle(s).

Garaging street address if other than address above
City
State	Texas
Zip code
County
*Name on vehicle title

 

Vehicle 1
*Year
*Make (Manufacturer)
*Model
VIN Number
Doors	(choose one) 2 4 5
Cost new $
Vehicle Identification Number (VIN)
Anti-theft device	(choose one) Yes No
Use	(choose one) Pleasure To and from work Business
Passenger restraint	(choose one) Automatic seat belts Manual seat belts
Air bags	(choose one) None Driver's side only Driver and passenger sides

Vehicle 2
Year
Make (Manufacturer)
Model
VIN Number
Doors	(choose one) 2 4 5
Cost new $
Vehicle Identification Number (VIN)
4x4	(choose one) Yes No
Anti-theft device	(choose one) Yes No
Use	(choose one) Pleasure To and from work Business
Passenger restraint	(choose one) Automatic seat belts Manual seat belts
Air bags	(choose one) None Driver's side only Driver and passenger sides

Vehicle 3
Year
Make (Manufacturer)
Model
VIN Number
Doors	(choose one) 2 4 5
Cost new $
Vehicle Identification Number (VIN)
4x4	(choose one) Yes No
Anti-theft device	(choose one) Yes No
Use	(choose one) Pleasure To and from work Business
Passenger restraint	(choose one) Automatic seat belts Manual seat belts
Air bags	(choose one) None Driver's side only Driver and passenger sides

Tell us about the driver(s) for this car, including you (if applicable).

Driver 1
First name
Last name
*Date of Birth	mm/dd/yyyy
*Drivers License Number	TX
*Gender	(choose one) Male Female
*Marital status	(choose one) Married Single Divorced Separated
Number of Years with a  Texas Drivers license	more than 3 years 2 years 1 year less than one year

Driver 2
First name
Last name
(required) Date of Birth	mm/dd/yyyy
(required) Drivers License Number	TX
Gender	(choose one) Male Female
Marital status	(choose one) Married Single Divorced Separated
Number of Years with a  Texas Drivers license	more than 3 years 2 years 1 year less than one year

Driver 3
First name
Last name
(required) Date of Birth	mm/dd/yyyy
(required) Drivers License Number	TX
Gender	(choose one) Male Female
Marital status	(choose one) Married Single Divorced Separated
Number of Years with a  Texas Drivers license	more than 3 years 2 years 1 year less than one year

Driver 4
First name
Last name
(required) Date of Birth	mm/dd/yyyy
(required) Drivers License Number	TX
Gender	(choose one) Male Female
Marital status	(choose one) Married Single Divorced Separated
Number of Years with a  Texas Drivers license	more than 3 years 2 years 1 year less than one year

*Have any of the above drivers had any traffic violations or accidents (regardless of fault) in the last 3 years?

(choose one) Yes No

If you answered "Yes," please describe below.

*Have any of the above drivers had any claims or losses in the last 3 years?

(choose one) Yes No

If you answered "Yes," please describe below. Include date and amount paid.

Tell us about the coverage you want.

*Limit of liability $	(choose one) 20/40/15 25/50/25 50/100/50 100/300/100 250/500/100
*Personal injury protection $	(choose one) No coverage 2,500 5,000 10,000
*Uninsured/underinsured motorist $	(choose one) No coverage 20/40/15 25/50/25 50/100/50 100/300/100 250/500/100
Comprehensive deductible $	(choose one) No coverage 50 100 200 250 500 1,000
Collision deductible $	(choose one) No coverage 250 500 1,000
Towing	(choose one) 0 20 80 120	miles
Rental reimbursement $	(choose one) None 20 25 30 35	per day

Tell us about your recent coverage.

*Do you own or rent your home?	(choose one) Own Rent
*Has there been a Homeowners insurance policy in force continuously for the past 6 months?	(choose one) Yes No
*Has there been a Personal Auto Liability  policy in force continuously for the past 6 months?	(choose one) Yes No
If yes, Liability Limits carried on prior policy?	(choose one) 20/40/15 25/50/25 50/100/50 100/300/100 250/500/100
If no, how long has there been a lapse of coverage?	(choose one) 10 days or less More than 10 days More than 30 days

Please provide any additional information or comments.