International Insurance of Georgia (IIG)

Personal Auto Application

Personal Auto Application
General Information
Applicant's Name:*
Current Home Address:*
City/State/Zip:*	City: State: ZIP:
County:*
Prior Address (if less than 6 months):
City/State/Zip:	City: State: ZIP:
County:
Phone Number:
E-Mail Address:

Name of carrier:

Expiration Date:

How long with current carrier?

Bodily Injury/Property Damage Limits

UM Split

Med-Pay

Collision Deductible:

Comprehensive Deductible:

Rental:

Towing:

Claims/Violations in the past 3 years

Vehicle Involved

Type of
Loss/Violation

Payoff (if claim)