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Telephone:
Local: (817)285-1800
Metro: (972)285-1800
Fax: (817)285-1818

TollFree:
(800)929-2424

Standard Insurance
8190 Precinct Line Rd
Suite 101
Colleyville, Texas 76034

Mail Payments to:
P.O. Box 650256
Dallas, Texas 75265

© 2012 Standard Insurance Agency
Our Privacy Policy

Application Progress

Personal Vehicle Information Drivers Additional Information Coverage Amounts


Personal Information

Please note: Protecting your identity is important to us. All information in this form is protected using 128 bit high-grade encryption.
Name:
Social Security Num:
Address:
City:
County:
State:
Zip Code:
Date of Birth:
D/Lic #:
D/Lic State:
Home Phone:
Employer:
Occupation:
Work Phone:
How Long?:
Email Address:



Vehicle Information

Vehicle #1
Veh ID# (VIN)
Year:
Make:
Model:
Lic Plate # /St
Veh Titled To:
Vehicle #2
Veh ID# (VIN)
Year:
Make:
Model:
Lic Plate # /St
Veh Titled To:
Vehicle #3
Veh ID# (VIN)
Year:
Make:
Model:
Lic Plate # /St
Veh Titled To:
Vehicle #4
Veh ID# (VIN)
Year:
Make:
Model:
Lic Plate # /St
Veh Titled To:


Driver Information

Driver #1
Driver Name:
Date of Birth:
DL # / State / Years Licensed:
Soc Sec #:
Relationship:
Occupation:
Employer:
Work Phone #:
Driver #2
Driver Name:
Date of Birth:
DL # / State / Years Licensed:
Soc Sec #:
Relationship:
Occupation:
Employer:
Work Phone #:
Driver #3
Driver Name:
Date of Birth:
DL # / State / Years Licensed:
Soc Sec #:
Relationship:
Occupation:
Employer:
Work Phone #:
Driver #4
Driver Name:
Date of Birth:
DL # / State / Years Licensed:
Soc Sec #:
Relationship:
Occupation:
Employer:
Work Phone #:


Additional Information

For each driver, list all tickets/accidents or claims for the last five years
(If NONE please state None)
Names and ages of children/step-children/everyone who lives with you
(If NONE, please state NONE)?
Names and ages of children/step-children who do not reside with you
(If NONE, please state NONE)?
Does any driver have a suspended license?  If yes, show name or driver, reason for suspension, suspension date
(If NONE, please state NONE).
Name and address of lien holder for each vehicle
(If NONE, please state NONE):
Name of previous insurance company
How long insured with Co.
If any claims were filed or paid by this company, list date and type of claim
(If NONE, please state NONE).

Current Coverage Amounts


Policy Item Vehicle #1 Vehicle #2
Liability Limits
Personal Injury Protection (PIP)
Uninsured/Under Insured Motorist
Comprehensive (Deductible)
Collision (Deductible)
Towing Coverage

 

Policy Item Vehicle #3 Vehicle #4
Liability Limits
Personal Injury Protection (PIP)
Uninsured/Under Insured Motorist
Comprehensive (Deductible)
Collision (Deductible)
Towing Coverage