Contact Information

Name
Street Address
City
State
Zip Code
County
Daytime Phone
Evening Phone
Fax
E-Mail address
Are you currently insured?	Yes No*
If you are not currently insured, please give the reason that you are not currently insured (for example, "This is my first car" or "My policy lapsed two months ago":
If currently insured, by what company?
Policy Expiration Date
How long have you been continuously insured?	Not insured Less than 6 months Less than 1 year More than 1 year 2 years 3 years 4 years 5 years
("Continuously Insured" means the length of time without a lapse in coverage.)

Driver Information

Name
Date of Birth
Marital Status	Married Single Divorced Widow(er)
Gender	Male Female
# of Years Licensed to Drive
# of Tickets in last 3.5 years	None 1 2 3+
# of Accidents (regardless of fault) in last 3.5 years	None 1 2 3+
Please give details regarding the tickets or accidents:

Additional Driver Information

How many miles is this vehicle driven to work or school each day (one way)?
Occupation
Drivers License Number

Vehicle Information

Year
Make (ex - Chevrolet)
Model (ex - Monte Carlo)
Body Type (Select all that apply): 2 Door 4 Door 4WD Van Pickup Wagon
Safety Features (Select all that apply): 1 Air Bag Dual Air Bags Daytime Running Lights Passive Alarm Auto Seat Belts Anti-lock Brakes
Vehicle ID #
Is this vehicle leased?	Yes No

Coverage Information

Comprehensive Deductible None $50 $100 $200 $250 $500 $1,000

Collision Deductible None $50 $100 $200 $250 $500 $1,000

Liability Coverages
Liability Coverage Minimum 25/50 50/100 100/300 250/500 300csl 500csl	Property Damage Minimum $10,000 $25,000 $50,000 $100,000	Uninsured Motorist Minimum 25/50 50/100 100/300 250/500 None	Personal Injury Protection Full Additional None

Additional Required Underwriting Information

Have you ever filed for bankruptcy?	Yes No
Do you own your home?	Yes No
What is your credit rating?	Excellent Fair Good Poor

Other types of insurance you have (check all that apply): Home Life Disability Long-term Care Business Auto Umbrella Business Flood Motorcycle Boat

Additional information, comments or questions:

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McKenzie Agency, Inc.
1315 N. County Road West
Odessa, Texas 79763

(432) 333-3532
(800) 395-3532 (tollfree)
e-mail: info@mckenzieins.com