SCCarInsurance.com: South Carolina Car Insurance

Personal Auto Application

User Information

Vehicle Information

General Information

Applicant Information

Years at previous address	:
Years at Current address	:
Previous Address(If less than 3years)	:
Vehicle #	:
Garaging Address if Diff From Above	:
Current Residence is	:

User Information

Vehicle Information

General Information

Vehicle	:
Cost New	:
Symbol Age Group	:
Terr	:
Mile 1 Way WK/SCHL	:
# Days Week	:
# WKS Month	:
Usage	:
Perform	:
Multicar	:
Car Pool	:
Gar Code	:
Odometer Reading	:
Annual Mileage	:
Govern Driver	:
Driver Use%(Each veh must equal 100%)	:
Class	:

Coverages/Premiums

Coverages	Limit of Liability	Vehicle #	Vehicle #
Single Limit Liability(CSL)	$EA Accident	$	$
Bodily Injury Liability	$EA Person $	$	$
Property Damage Liability	$EA Accident	$	$
Medical Payments	$EA Person	$	$
Uninsured/Underinsured Motorists BI	$EA Person $EA Accident	$	$
Uninsured Motorists BI	$EA Person $EA Accident	$	$
Uninsured Motorists PD	$EA Person $Deductible	$	$
Alt Economic Loss COV BI	$EA Person $EA Accident	$	$
Comprehensive/OTC DED	$ $	$	$
Collision DED	$ $	$	$
ACV UNLESS AMOUNT STATED	$ $	$	$
Towing & Labor	$ $	$	$
Trans Exp/Rental RE	$ $	$	$


Resident & Driver Information(List all residents & dependents(licenced or not) and regular operators)

Name(as it appears on Licence)	Sex	MAR STAT	REL to APPLIC	Date of Birth	OCC	DATE LIC	STDT >100	Good STDT	DRV Train	ACC Prev CSE Date	Drivers Licence

Has any Driver shown above had an accident	:
If yes,indicate below:
Masonary	:
Date of Accident/Conviction	:
Description Of Accident or Conviction	:
Place Of Accident/Conviction	:
BI or Death	:
Amount Of Property Damage	:

Additional Interest

Employment Information

Prior Coverage

User Information

Vehicle Information

General Information

With the exception of any encumbrances,are any vehicles not solely owned by registered to the applicant?	:
Any Car modified/special equipment?	:
Any existing damage to vehicle?	:
Include damaged glass	:
Any Other Losses Incured	:
Any Other Insurance in Household	:
Include any provided by employer	:
Any Other Insurance with this Company	:
If Yes,List Policy Numbers	:
Any Household Number in military service?	:
If Yes,List Driver Number	:
Any Drivers License been suspended/revoked	:
Any Driver have Physical/Mental Impairment	:
If Yes,List Driver Number	:
Any Financial Responsibility Flying	:
If Yes,List Driver Number and date of Flying	:
Has Insurance been transferred within agency	:
Any Coverage Declined,cancelled or non-renewed during the last 3 years	:
Has Applicant Has a Foreclosure,repossession,bankruptcy,judgement or lien during the past 5years	:
Is this brokered business to the agent?	:
Has Agent Inspected Vehicle	:

Remarks	: