Auto Insurance Discount Worksheet

Please answer all applicable questions for maximum discount eligibility.

Required fields are denoted by an asterisk ()*
* First Name:
* Last Name:
* Daytime Telephone Number:
* E-Mail address:	Note: use your full email address. Example: jdoe@aol.com

Does your Anti Theft Device also have a Special “Chip Key”?	Yes No N/A
Does any listed driver qualify for the Good Student Discount? A good Student is qualified by maintaining a B average (3.0)	Yes No N/A
Are you a member of any Motor Club? If so, which Club?	Yes No N/A
Have you completed any Advanced Driver Training Instruction, in addition to the Mass Drivers Education Course?	Yes No N/A
Do you have any other active Auto Policy in your Household?	Yes No N/A
Do you currently own a home/dwelling NOT currently insured by the Toole Agency? If so, please provide information.	Yes No N/A
Do you use Public Transit on a regular basis?	Yes No N/A
What is your annual mileage per vehicle?
Do you own a Hybrid Vehicle? Year/Make/Model	Yes No N/A