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DRIVER INFORMATION #1
Name:
Birthdate:
Sex (M/F):
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
If YES to SR22 filing, why needed? (list accident/cite)
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:
Make & Model:
Annual Mileage:
Vehicle Value:
$
If towing a trailer, boat, or 5th wheel, what is year, make & model?
Towed Vehicle Value:
$
VEHICLE #1 COVERAGES:
Limits of Liability:
$15/30 BI / 10 PD
$25/50 BI / 25 PD
$50/100 BI / 25 PD
$100/300 BI / 50 PD
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Annual Mileage:
Vehicle Value:
$
If towing a trailer, boat, or 5th wheel, what is year, make & model?
Towed Vehicle Value:
$
VEHICLE #2 COVERAGES:
Limits of Liability:
$15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 25 PD
$10/300 BI / 50 PD
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
Comments or Remarks:
(List additional drivers, autos, etc. here)
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