Thank you for contacting Fournier Insurance Solutions.
The information collected from this questionnaire will help us
prepare an auto proposal for you.
This will take approximately 10 minutes to complete.
If you have current coverage, please have your current policy available.
How did you hear about us?

Your name: *

Date of Birth: *

Drivers License number:

2nd Insured's name: *

If there is no additional insured, please input "none."
2nd Insured's Date Of Birth:

2nd insured's Drivers License number:

Day time contact phone number(s): *

Garaging Address of vehicle(s): *

Mailing address, if different:

Your employer and occupation: *

Number of miles driven one way to work?

Education Level: *

Marital Status: *

Do you have current coverage? *

Current Auto Insurance Company: *

How long have you had your current coverage? *

Is your current coverage being non-renewed or cancelled, why? *

The following questions pertain to your current coverage:

Please have your current coverage information available. If you are unsure of current coverage, please put "unknown" as your answer.
Liability Limits: *

Personal Injury Protection: *

Under insured Motorist: *

Comprehensive Deductible: *

Collision Deductible: *

Towing Coverage? *

Rental Car Coverage? *

Glass Coverage? *

Are you interested in obtaining coverage on any of the following: *

Please list any additional drivers in your household and their date of birth, in addition to:


John Doe, 8/5/1990
Jane Smith, 4/22/1997
Do you have any young drivers in your household? *

Have they completed Driver's Training?

Are they enrolled in school? *

Are their grades above a 3.0 GPA *

Is your student driver away, over 100 miles, from home? *

Have you had any accidents in the last 5 years? *

Please explain the accident(s): *

Have you had any tickets in the past 3 years? *

Please explain the ticket(s): *

Please list all vehicles for your household: *

Please include year, make, model, and VIN#.
Are any of your vehicles financed? *

Do you have any of the following recreational vehicles? *

Do you belong to AAA?

Thank you {{answer_8093114}} for taking the time
to complete this questionnaire for an auto policy proposal.
One of our agents will be contacting you soon.
FiS Home Page