CA Low-Cost Auto Insurance Application - Consumer Friendly Insurance Services

First Name *

Middle Initial *

Last Name *

Marital Status *

Home Phone

Work Phone

Mobile Phone *

Driver's License Number *

State Licensed *

Employment Status

Vehicle Usage Code *

Email Address *

Address 1 *

Address 2 *

City *

County *

State *

Zip Code *

Mailing address different from above? *YesNo

Mailing Address (only if different from above)

Does applicant have a former address within 3 years? *YesNo

Former Address Within 3 Years (only if Yes above)

Household Annual Gross Income ($) *

Total Number of People in Household *

Additional Operator — First Name *

Additional Operator — Middle Initial *

Additional Operator — Last Name *

Additional Operator — Marital Status

Additional Operator — Has operator been licensed continuously for the past 3 years? *YesNo

Additional Operator — Driver's License Number *

Additional Operator — State Licensed

Additional Operator — Relationship to Applicant

Additional Operator — Annual Income ($) *

Additional Operator — Employment Status

Additional Operator — Applicant financially responsible for this person? *YesNo

Additional Operator — Required to file SR-22? *YesNo

Non-Driver — First Name *

Non-Driver — Middle Initial *

Non-Driver — Last Name *

Non-Driver — Relationship to Applicant

Non-Driver — Annual Income ($) *

Non-Driver — Applicant financially responsible for this person? *YesNo

Additional Household Members (if more than the blocks above)

Have you been involved in any accident in which you were principally at fault involving bodily injury or death? *YesNo

Have you been involved in any accident in which you were principally at fault that resulted in only property damage? *YesNo

Have you been involved in any accident in which you were considered to be not at fault? *YesNo

Accident Details (if Yes to any question above)

VIN *

Make *

Model Year *

Model *

County of Residence (Vehicle) *

State Registered In *

Current Value of Vehicle ($) *

Purchase Date (MM/YYYY) *

Purchased New? *YesNo

Is the vehicle garaged at the applicant's address? *YesNo

Is the vehicle registered at the applicant's address? *YesNo

Does the applicant own the vehicle? *YesNo

Is there a co-registrant? *YesNo

Vehicle Notes (only if No above, or if there is a co-registrant)

Bodily Injury *

Property Damage *

Medical Payments

Uninsured Motorist Bodily Injury

Additional Vehicle (optional)

Has the applicant had insurance in the past? *YesNo

Is there a policy currently in effect for the vehicle being insured on this application? *YesNo

Are any other vehicles owned by any member of household? *YesNo

If Yes, give name of insurer *

If Yes, provide type of vehicles *

Do you own any vehicles that are not eligible for coverage on a Low Cost Policy? *YesNo

Does the applicant wish to elect a third party designee? *YesNo

Third Party Designee Name (only if Yes above) *

Application Remarks

Confirmation *I confirm the information above is true and complete to the best of my knowledge, and I understand this is a request for the agency to review it — not a bound policy or a quote.

Contact Consent *I agree the agency may contact me by phone or email about this request.