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Sample Lead: Auto
| Contact Information: | |||
|---|---|---|---|
| Name: | Mark Smith | Email: | marksmith@yahoo.com |
| Address: | 123 Main St | Phone: | (555) 666-7777 |
| City, State, Zip: | Chicago, IL, 60614 | Alt. Phone: | |
| Prior Insurance Information: | |||
| Company: | Nationwide | Policy Expires: | 5 / 19 / 2008 |
| Liability Limits: | $50,000 / $100,000 / $25,000 | Prior Coverage: | 4 Years |
| Desired Coverage Information: | |||
| Bodily Injury: | $ 100,000 / $ 300,000 | Credit Rating: | Good |
| Property Damage: | $ 50,000 | Home Owner: | Yes |
| Under/Uninsured: | $ 100,000 / $ 300,000 | Medical Payments: | $ 500 |
| Driver #1: | |||
| Driver Name: | Mark Smith | Relationship: | Primary |
| License Status: | Active | Gender: | Male |
| Date of Birth: | 7 / 12 / 1955 | Marital Status: | Married |
| Age Licensed: | 16 | State Licensed: | IL |
| Occupation: | Advertising / Public Relations | Education: | Bachelors Degree |
| SSN: | 222-55-xxxx | License Number: | L555666 |
| Suspension: | None | SR-22 Filing: | No |
| Violations: | None | ||
| Driver #2: | |||
| Driver Name: | Lauren Smith | Relationship: | Spouse |
| License Status: | Active | Gender: | Female |
| Date of Birth: | 3 / 17 / 1972 | Marital Status: | Married |
| Age Licensed: | 18 | State Licensed: | IL |
| Occupation: | Education / Training | Education: | Bachelors Degree |
| SSN: | License Number: | ||
| Suspension: | None | SR-22 Filing: | No |
| Violations: | None | ||
| Driver #3: | |||
| Driver Name: | Allison Smith | Relationship: | Child |
| License Status: | Active | Gender: | Female |
| Date of Birth: | 2 / 15 / 1986 | Marital Status: | Single |
| Age Licensed: | 16 | State Licensed: | IL |
| Occupation: | Student GPA: 3 | Education: | High School Diploma |
| SSN: | License Number: | ||
| Suspension: | None | SR-22 Filing: | No |
| Violations: | None | ||
| Vehicle #1: | |||
| Year, Make: | 2005 JEEP | Primary Driver: | Mark Smith (Driver #1) |
| Model: | GRAND CHEROKEE LAR/COL/FR | Ownership: | Owned |
| Vehicle Use: | Commute Work | Annual Milage: | 15000 - 18000 |
| Rental Coverage: | Yes | Roadside Service: | Yes |
| Deductibles: | Comprehensive: $ 500 | ||
| Collision: $ 500 | |||
| Vehicle #2: | |||
| Year, Make: | 2006 SUBARU | Primary Driver: | Lauren Smith (Driver #2) |
| Model: | FORESTER 2.5X | Ownership: | Financed |
| Vehicle Use: | Commute Work | Annual Milage: | 7500 - 10000 |
| Rental Coverage: | Yes | Roadside Service: | Yes |
| Deductibles: | Comprehensive: $ 500 | ||
| Collision: $ 500 | |||
| Vehicle #3: | |||
| Year, Make: | 2002 HONDA | Primary Driver: | Allison Smith (Driver #3) |
| Model: | CIVIC HX | Ownership: | Owned |
| Vehicle Use: | Commute School | Annual Milage: | 15000 - 18000 |
| Rental Coverage: | No | Roadside Service: | No |
| Deductibles: | Liability Coverage Only | ||