LAURENCE COLE INSURANCE AGENCY
214‑823-COLE (2653)
FAX 214-823-3805
AUTO WORKSHEET
NAME: __________________________________________________________________________________
HOW DID YOU HEAR ABOUT US? CLIENT REFERRAL YELLOW PAGES OTHER____________
ADDRESS: _______________________________________________________________________________
RENT/OWN: _____________________________HOW LONG: ________________
PHONE HOME:( )______________________ WORK:( )_____________________________
FAX NUMBER: _____________________________ E-MAIL: ____________________________________
DATE OF BIRTH: ____________________________ SS#: _______________________________________
DRIVERS LICENSE #: _____________________________STATE: _______ 1ST LICENSED: ____/_____
OCCUPATION: _______________________________ EMPLOYER: ______________________________
TICKETS/CLAIMS/ACCIDENTS: __________________________________________________________
#2. NAME: ___________________________________________________RELATIONSHIP:____________
DATE OF BIRTH: ____________________________ SS#: _______________________________________
DRIVERS LICENSE #: _____________________________STATE: _______ 1ST LICENSED: ____/_____
OCCUPATION: _______________________________ EMPLOYER: ______________________________
TICKETS/CLAIMS/ACCIDENTS: ___________________________________________________________
PRIOR COVERAGE? COMPANY & POLICY #: _______________________________________
VEH #1: (MAKE/MODEL & VIN #)____________________________________________________________
LIEN HOLDER: _________________________________________________ LEASED: __________________
ADDRESS: _________________________________________________________________________________
VEH #2: (MAKE/MODEL & VIN #)____________________________________________________________
LIEN HOLDER: _________________________________________________ LEASED: __________________
ADDRESS: __________________________________________________________________________________
AUTO * HOMEOWNERS * LIFE * COMMERCIAL
LAURENCE COLE INSURANCE AGENCY
214‑823-COLE (2653)
FAX 214-823-3805
HO/RENTERS WORKSHEET
NAME: __________________________________________________________________________________
HOW DID YOU HEAR ABOUT US? CLIENT REFERRAL YELLOW PAGES OTHER____________
PROPERTY ADDRESS: ___________________________________________________________________
CITY: __________________________ STATE: ____________ ZIP: ____________
PHONE: HOME( )______________________ WORK( )_____________________________
FAX NUMBER: _____________________________ E-MAIL: ____________________________________
DATE OF BIRTH:____________________________ SS#:________________________________________
OCCUPATION:_______________________________ EMPLOYER:______________________________
DATE OF BIRTH:____________________________ SS#:_______________________________________
PRIOR COVERAGE? COMPANY & POLICY #:____________________________________
PRIOR ADDRESS: (WITHIN LAST 2 YRS) __________________________________________________
ANY LOSSES:_____________________________________________
AMOUNT OF COVERAGE: $________________MORTGAGE AMOUNT:$_______________________
CREDITS: NON-SMOKER: Y N AGE 50 PLUS: Y N
SECURITY DEVICES: DEAD BOLTS SMOKE ALARM FIRE EXT.
AUTO/HO Y N MONITER ALARM: Y N
TYPE OF DWELLING: PVT DWELLING CONDO APT.
YEAR BUILT: ___________SQUARE FEET: _______________ CONSTRUCTION: _______________
NO. OF BATHROOMS: __________FIREPLACES: ________________ STORIES: _______________
TYPE OF ROOF: _____________________AGE OF ROOF: _________________________
UPDATES: PAINT: ____________PLUMBING: __________ WIRING: _________________
SCHEDULE ITEMS: JEWELRY/FURS/FINE ARTS ECT. ______________________________________
LIEN HOLDER: ______________________________________LOAN #_____________________________
ADDRESS: ________________________________________________________________________________
TITLE CO: _________________________________________CONTACT:______________________________
PHONE: __________________________________FAX: _____________________________________________