John B. Andrews, Inc.
30376 Esperanza, Suite 300
Rancho Santa Margarita, Ca. 92688
Office: (949) 589-1114
E-mail: john@rsminsurance.com
   
 


 
















Contact Information
  Your Full Name:
  Address:
  City:
  State:
  Zip:
  Home Phone: area code
  Work Phone: area code    Ext.
  Fax Phone: area code   
  Email:   

Vehicle 1
  Year:
  Make:
  Model w/Trim ( XE, LE, etc.):
  ABS Brakes? Yes No
  Annual Mileage:
  Date Purchased:

Vehicle 2
  Year:
  Make:
  Model w/Trim ( XE, LE, etc.):
  ABS Brakes? Yes No
  Annual Mileage:
  Date Purchased:

Vehicle 3
  Year:
  Make:
  Model w/Trim ( XE, LE, etc.):
  ABS Brakes? Yes No
  Annual Mileage:
  Date Purchased:

Vehicle 4
  Year:
  Make:
  Model w/Trim ( XE, LE, etc.):
  ABS Brakes? Yes No
  Annual Mileage:
  Date Purchased:

Operator 1
  Name: FemaleMale
  Marital Status:  
  Date of Birth: -- (mm/dd/yyyy)
  Vehicle Driven: # 1  # 2 # 3 # 4  
  % Use of each vehicle Veh.1 - Veh.2 - Veh.3 - Veh.4
  Vehicle Use: miles to work/school 1 way:
  Moving Violations( Last 3 Years): //1st. // 2nd. // 3rd.
  Accidents (list all accident "Dates" in the (Last 5 years):: //1st. // 2nd. // 3rd.
  "B" Average for Student? Yes  No

Operator 2
  Name: FemaleMale
  Marital Status:   
  Date of Birth: -- (mm/dd/yyyy)
  Vehicle Driven: # 1  # 2 # 3 # 4  
  % Use of each vehicle Veh.1 - Veh.2 - Veh.3 - Veh.4
  Vehicle Use: miles to work/school 1 way:
  Moving Violations( Last 3 Years): //1st. // 2nd. // 3rd.
  Accidents (list all accident "Dates" in the (Last 5 years):: //1st. // 2nd. // 3rd.
  "B" Average for Student? Yes  No

Operator 3
  Name: FemaleMale
  Marital Status:   
  Date of Birth: -- (mm/dd/yyyy)
  Vehicle Driven: # 1  # 2 # 3 # 4  
  % Use of each vehicle Veh.1 - Veh.2 - Veh.3 - Veh.4
  Vehicle Use: miles to work/school 1 way:
  Moving Violations( Last 3 Years): //1st. // 2nd. // 3rd.
  Accidents (list all accident "Dates" in the (Last 5 years):: //1st. // 2nd. // 3rd.
  "B" Average for Student? Yes  No

Operator 4
  Name: FemaleMale
  Marital Status:   
  Date of Birth: -- (mm/dd/yyyy)
  Vehicle Driven: # 1  # 2 # 3 # 4  
  % Use of each vehicle Veh.1 - Veh.2 - Veh.3 - Veh.4
  Vehicle Use: miles to work/school 1 way:
  Moving Violations( Last 3 Years): //1st. // 2nd. // 3rd.
  Accidents (list all accident "Dates" in the (Last 5 years):: //1st. // 2nd. // 3rd.
  "B" Average for Student? Yes  No

Prior Insurance
  Company Name:
  Policy Number:
  Expiration Date: //  (mm/dd/yyyy)
  How Long?:

Coverage
  Bodily Injury::
  Property Damage:  
  Uninsured/Underinsured Motorist:  
  Medical payments:

Physical Damage
  Vehicle # 1 Comprehensive Deductible:
  Collision Deductible:   
  Rental Reimbursement:
  Towing:
 
  Vehicle # 2 Comprehensive Deductible:
  Collision Deductible:   
  Rental Reimbursement:
  Towing:
 
  Vehicle # 3 Comprehensive Deductible:
  Collision Deductible:   
  Rental Reimbursement:
  Towing:
 
  Vehicle # 4 Comprehensive Deductible:
  Collision Deductible:  
  Rental Reimbursement:
  Towing:

Additional Comments