Auto Insurance Renewal Questionnaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 3Please complete this questionnaire within 15 days from your receipt of the notification email. You must complete and submit this questionnaire in its entirety for renewal of your policy. Please fill in all applicable fields (* denotes a required field). Once completed, please click the Submit button at the bottom of this page. Name of Person Responding to Questionnaire *FirstLastRespondent’s Email Address *Respondent’s Phone Number (Mobile Preferred) *Policy Number *Policyholder Name *FirstLastState *— Select State —PennsylvaniaMarylandAgentNextNumber of drivers over the age of 14 in your household who are licensed, not licensed, or currently suspended and anyone else who may use your vehicle: * Drivers Provide the following information for all drivers identified in the previous question. If you have more than one driver, click the plus sign to add additional Drivers.Name *Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Drivers License Number *Relationship to Insured * Add a Driver Remove PreviousNextNumber of vehicles in the household * Vehicles Provide the following information for each Vehicle identified in the previous question. If you have more than one Vehicle, click “+ Add” to add additional Vehicles.Vehicle Year *Vehicle Make *Vehicle Model *Primary Operator's Name *Garage City *Garage State *Is the Vehicle Used to Drive to Work? *YesNoIs the Vehicle Used to Drive to School? *YesNoIs this vehicle used for Business Purposes? *YesNoIf you use the Vehicle for Business Purposes, please describe how your vehicle is used. For example, do you travel to job sites, call on clients, use it for delivery, transport customers, or other uses? Is the Vehicle Registered to the Policyholder? *YesNoIf the vehicle is not registered to the Policyholder, provide the first and last name of the registered owner. Add a Vehicle Remove By submitting this response, I acknowledge that to the best of my knowledge and belief all information on this form, whether pre-filled or filled in by me, is accurate and true. I understand that this is an important element in determining my premium, and that failure to confirm and provide complete and accurate information could result in loss of insurance coverage. Maryland Fraud Statement: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Pennsylvania Fraud Statement: Any person who knowingly and with intent to injure or defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up to $15,000. PreviousSubmit
