Pennsylvania Automobile Questionnaire

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# Miles Each Way

Annual Mileage

Leased/Financed

Arthur Hall Insurance | 101 East Chestnut St. | Post Office Box 512 | West Chester, PA 19381
610-696-2394 | Fax: 610-436-9675

To speak to a customer service representative,
call our office at 610-696-2394 during normal business hours.

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Required information*

*Date:

*Applicant First Name:

*Applicant Last Name:

*Applicant SS #:

000-00-0000

*Applicant DOB:

mm/dd/yyyy

Co-Applicant First Name:

Co-Applicant Last Name:

Co-Applicant SS #:

000-00-0000

Co-Applicant DOB:

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Expiration Date:

mm/dd/yyyy

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Property Damage:

Uninsured/Underinsured Motorists:

Stacked Non Stacked Full Tort Limited Tort

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Current Drivers

Name	DOB	Date Licensed	State	License Number	Primary Vehicle Driven

Are all resident drivers listed?

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Accidents

Date	Driver & Description	Amount Paid

Violations

Date	Driver & Description	Violation

Automobiles

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or call us now at 610-696-2394. We will be glad to help you
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Arthur Hall Insurance
Pennsylvania Office | 101 East Chestnut St., P.O. Box 512, West Chester, PA 19381-0512
610-696-2394 | Fax: 610-436-9675
Delaware Office | 4 West Rockland Rd., P.O. Box 70, Montchanin, DE 19710
302-658-0100 | Fax 302-658-2575
Voted the #1 Insurance Agency in Chester County (1993 - 2008)