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Automobile Insurance Availability form

 

Consumer



Last Insurer on Risk

Last Broker on Risk

Cancellation (if applicable)

Insurance Companies or brokers contacted having refused coverage (minimum 5 contacts)

Do you hold any other insurance coverage?

Type of insurance

check the personal information given to GAA with insurance companies and brokers you have contacted

obtain from such insurance companies and brokers any other missing personal information relevant to the underwriting of the risk, and do you authorize such insurance companies and brokers to disclose this information to GAA;

disclose to an insurance company or broker that you have not contacted any personal underwriting information required if GAA approaches such an insurance company or broker to try and obtain an automobile insurance policy on your behalf.

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