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Auto Insurance Application

Step 1 of 6

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Welcome to The Whitlock Group's Auto Insurance Application

The information submitted will be used to quote your insurance with up to seven (7) companies. This form will take approximately 15 minutes to complete.
Complete the form as fully as possible as all questions are tied to rate surcharges and credits.

* indicates required

Before starting, have the following available for reference
- Current (or upcoming renewal) automobile policy declaration page(s) for all vehicles - you will need: Year, Make, Model, Trim, and Vehicle Identification Number (VIN)
- Driver’s license information for all drivers living in your residence or full-time student(s) away from home (Full name on license, date of birth, State, drivers license number)
- Details regarding any Claims, Losses, Accidents, and/or Traffic Citations for the last 5 years
About You & Your Family
Primary Insured Name*
First Middle Last Suffix
Applicant's Home Address*
Street Address Address Line 2 City State ZIP Code
County
Phone*
(###)###-####
Email*
Have You Lived at this Address Longer than 3 Years?*
- Yes
- No
Prior Address
Street Address Address Line 2 City State ZIP Code
Do You Have an Alternate Mailing Address?*
- Yes
- No
Alternate Mailing Address
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM
DD
YYYY
Occupation*
Marital Status*
- Single
- Engaged
- Married
- Domestic Partnership
- Separated
- Divorced
- Widowed
Spouse/Fiancé/Partner's Name
First Middle Last Suffix
Their Date of Birth
MM
DD
YYYY
Their Occupation
If Engaged, Will Your Partner Be Insured With You?
- Yes
- No
Does Your Former Partner Still Reside in the Household?
- Yes
- No
Effective Date of Policies*
MM
DD
YYYY
Upload Your Insurance Declaration Pages
Upload a current (or upcoming renewal) copy of Declaration Page(s) for each policy line of business to be quoted.
Drop files here or

Max. file size: 300 MB.

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Household Driver Information
Did You Upload Your Auto Policy Dec Pages?*
- Yes
- No
Driver's License Number*
State Licensed*
Name As it Appears on Driver's License*
List Any Additional Drivers Over the Age of 15 in Household
Use "+" to add more.
First Name Middle Initial Last Name Suffix Date of Birth (MM/DD/YYYY) Gender (M/F) Marital Status Relationship to Applicant License Number License State
Current Auto Insurance Company*
Have You Taken A Defensive Driving Course in the Past Three (3) Years?*
Possible discounts are available if yes.
- Yes
- No
Any Children Currently Away at School?*
- Yes
- No
If Yes:
- <100 Miles
- >100 Miles, no car
Driver Training Course?*
- Yes
- No
Financial Responsibility Filing SR-22?*
- Yes
- No
If Yes, Please List the Date and Filing Number:
Good Student?
A/B Average
- Yes
- No
Driving History: Tickets/Violations*
• An Incident is defined as a traffic violation, accident, rental-reimbursement, roadside assistance, or glass breakage.
• Use "+" to add more.
• Please enter any and all claims/tickets or violations for the last five years.
• IF YOU DO NOT HAVE ANY CLAIMS, PLEASE ENTER "NONE" IN THE BOXES BELOW.
Driver Violation Date (MM/DD/YYYY) Violation Description
Driving History: Claims & Accidents*
• An Incident is defined as a traffic violation, accident, rental-reimbursement, roadside assistance, or glass breakage.
• Use "+" to add more.
• Please enter any and all claims or acciendents for the last five years. • Include a brief description of the claim (i.e. Not at Fault/At Fault Accident, Comprehensive, Roadside Assistance, etc.).
• IF YOU DO NOT HAVE ANY CLAIMS, PLEASE ENTER "NONE" IN THE BOXES BELOW.
Driver Incident Date (MM/DD/YYYY) ($) Amount Paid (Approximately) Description of Claim

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Vehicle Information
Enter for Each Owned Vehicle
• Use "+" to add more.
• NOTE: Trim & Body Style are Optional.
• For Usage, please list whether your vehicle is used for Pleasure, Commute to School/Work, Business Use, Farm Use, or Show Only.
• For Mileage, please enter the distance to work or school ONE WAY.
• For Driver, enter the name of the individual that most often drives the vehicle. Be sure to include all drivers.
Year Make Model Trim/Body Style 17-Digit VIN Usage Assigned Driver Annual Milage Miles to Work/School Lease or Own
Do Any of the Autos Listed Currently Have Existing Dents, Cracks, or Damage, Including the Glass/Windshield?*
- Yes
- No
If Yes, Please List the Vehicles with Damage/Glass Damage.
List Any Vehicles NOT Garaged at the Primary Home Address
Use "+" to add more.
For example, any vehicles away with a student at college would be listed here. Be sure to include all drivers. For location, you may enter a city/state or a specific place, such as a college's name.
Driver Make/Model Location

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Limits
Liability
Please select the option that most closely matches. The format is: Bodily Injury per Person / Bodily Injury per Accident or Combined Single Limit.
Property Damage Liability Limit
What is Your Medical Payment?
Uninsured/Underinsured Motorists Limits
Property Damage Limits for Uninsured/Underinsured Motorists
Uninsured/Underinsured Motorists Property Damage Deductible (in Dollars)
Comprehensive Deductible (in Dollars)
Do not include a dollar sign '$'
Collision Deductible (in Dollars)
Do not include a dollar sign '$'
Include Rental Reimbursement?*
- Yes
- No
Include Towing Service?*
- Yes
- No
Include Gap Coverage?*
Gap Coverage is Generally Offered When the Value of the Vehicle is Less Than the Lease or Loan Amount.
- Yes
- No

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Claims, Credits & Discounts, & General Questions
NOTE: Discounts are possible and not 100%. This varies by carrier.
Any Lapse in Coverage in the Past 5 Years?*
- Yes
- No
- Not Applicable/First Time Buyer
How Long Have You Been With Your Curent Insurance Company?
Interested in Telematics?*
A telematics program collects data on driving habits from a mobile phone app while you drive and can be used to determine if a driver qualifies for discounts.
- Yes
- No

Save and Continue Later

Other Insurance
Would You Like Quotes on Any Additional Items? Check All that You Are Interested In.
An agent will be in touch to gather more information for lines outside of home and auto policies.
- Homeowners/Renters
- Personal Umbrella/Excess Liability
- Builders Risk/Vacant Property/Vacant Home
- Classic/Collector Automobile
- Flood or Earthquake
- Inland Marine/Personal Floater (i.e. Jewelry, Art Work, Collectibles, etc.)
- Landlord/Dwelling Fire/Tenant/Short-Term Rental
- Motorcycle/Moped/Scooter/Dirtbike/ATV/Golf Cart
- Recreational Vehicle (RV)/Camper/Motorhome/5th Wheel
- Watercraft/Boat/Jetski/Yacht
- Other
NOTE: Once your application is submitted, one of our Agents will contact you with quotes or to request additional information.
Remarks
Use this box to provide additional information, if needed.
CAPTCHA

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Email*
Phone
This field is for validation purposes and should be left unchanged.

The Whitlock Group

2915 Premiere Parkway, Suite 120
Duluth, Georgia 30097

Main Office Number: 678-906- 2008
Office Fax: 855-906- 2012

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Client Portal

Insurance
- Commercial Insurance
- Personal Insurance
Analytics
Risk Management
Industry Specialties
Insurance Carriers
About Us
Blog

Insurance
- Commercial Insurance
- Personal Insurance
Analytics
Risk Management
Industry Specialties
Insurance Carriers
About Us
Blog

First Name	Middle Initial	Last Name	Suffix	Date of Birth (MM/DD/YYYY)	Gender (M/F)	Marital Status	Relationship to Applicant	License Number	License State

Driver	Violation Date (MM/DD/YYYY)	Violation Description

Driver	Incident Date (MM/DD/YYYY)	($) Amount Paid (Approximately)	Description of Claim

Year	Make	Model	Trim/Body Style	17-Digit VIN	Usage	Assigned Driver	Annual Milage	Miles to Work/School	Lease or Own

Auto Insurance Application

Auto Insurance Application

Step 1 of 6

Welcome to The Whitlock Group's Auto Insurance Application

About You & Your Family

Household Driver Information

Vehicle Information

Limits

Claims, Credits & Discounts, & General Questions

Other Insurance