Phone 831-462-3222 • Fax 831-462-3251
6990 Soquel Dr., Aptos, CA 95003 •
sean(at)rovaiinsurance.com (replace (at) with @ when emailing)
Auto
* Indicates Required Field
Please fill out the form below and submit for all drivers in your household:
*Year:
*Make:
*Model:
VIN:
*Current Liability Limits:
Do you currently have other coverages such as comprehensive
and collision coverage, towing, or rental reimbursement?
*
Yes
No
If so, please list the deductibles and limits you currently carry:
*Name:
*Phone Number:
Fax Number:
*Email:
*Preferred Means Of Contact:
Email
Phone
Fax
*Date Of Birth:
*Address:
*City:
*State/Province:
*Zip/Postal Code:
Drivers License Number:
Social Security Number:
*Do You Have A Degree?:
Yes
No
*If so, in what field?
*Occupation:
Which auto do you use to commute?:
*
How many miles do you commute one way?:
*
How many days do you commute?:
*
*Are you a full-time student?:
*
Yes
No
If so, do you have a 3.0 or higher GPA?:
*Have you had any at-fault accidents within the past 6 years?:
*
Yes
No
If so, please state dates and occurrances of accidents:
*Have you received any tickets within the past 6 years?
*
Yes
No
If yes, please state the date of occurrence and the reason for the ticket:
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