Instructions
Please fill in all fields that apply to you as the form has many required fields.  If currently insured, your policy's declaration page will have much of the needed information. Type "DON'T KNOW" in any field that is required, but you DO NOT KNOW the answer.

ABOUT YOU
Name

 

Street Address

 
(not a P.O.Box) 

City

State

Zip Code

Daytime Phone

Evening Phone

Fax

E-mail Address

Are you currently insured?

Yes No CHECK ONE

Current Company

Expiration Date

Policy Number 

YOUR DRIVER DETAILS
Driver Name

Date of Birth

Marital Status # Yrs Licensed MOVING VIOLATIONS in LAST 5 yrs Accidents in LAST 5 yrs

1

2

3

Give details of tickets or accidents here:
 

 
ADDITONAL DRIVER INFORMATION
Driver Vehicle Driven & 
1-Way Miles to Work		 OCCUPATION Drivers License # Social Security #

1

Drives Vehicle #
 
miles to work

2

Drives Vehicle # 

 
miles to work

3

Drives Vehicle # 


miles to work

 

VEHICLE INFORMATION

Vehicle

Year (1986)

Make  (Nissan)

Model (Sentra XE)

Body Type
(Select all that apply):

1

2dr 4Dr Pickup Van Wagon 4WD

2

 

 

2dr 4Dr Pickup Van Wagon 4WD

3

 

 

2dr 4Dr Pickup Van Wagon 4WD

 
SAFETY FEATURES

Vehicle

Select all that apply.

1

1 Air Bag Dual Air bags Anti-Lock Brakes Passive Alarm Daytime Run Lights Auto Seat Belts

2

1 Air Bag Dual Air bags Anti-Lock Brakes Passive Alarm Daytime Run Lights Auto Seat Belts

3

1 Air Bag Dual Air bags Anti-Lock Brakes Passive Alarm Daytime Run Lights Auto Seat Belts

 
DEDUCTIBLES

Vehicle

Vehicle Identification #

Vehicle
Leased?

Comprehensive
Deductible:

Collision
Deductible:

1

2

3

 
VEHICLE FINANCE INFORMATION

If any of the vehicles are leased, please fill in the following finance information
Vehicle Bank Name / Address Loan Number Loss Payee Additional Insured
1 yes yes
2 yes yes
3 yes yes

 

 
LIABILITY

Liability Coverage:

Property Damage:

Uninsured Motorists

Personal Injury Protection

 

YOUR FINANCIAL DETAILS

Ever Filed For Bankruptcy?

Yes No

Is Your Credit Rating

Have you completed an Accident Prevention Course in the last 3 years?

Yes No

Do you own your home?

Yes  No

Please use the box below for comments or extenuating circumstances.
Please Press Submit ONCE and wait for confirmation
GCS Mortgage, Inc. 31 East 32nd Street, 4th Fl. New York, NY 10016 Tele: 212 545-9201 Fax: 212 447-4890 E-Mail: info@gcsmortgage.com