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:
Describe Accidents in last 36 Months:
Describe tickets in last 36 months:
Describe tickets or accident more than 3 years ago, but less than 5 years ago:
Does Driver need an SR22 FILING?
Yes
No
Daily commute in ONE WAY miles:
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:
Describe Accidents in last 36 Months:
Describe tickets in last 36 months:
Describe tickets or accident more than 3 years ago, but less than 5 years ago:
Does Driver need an SR22 FILING?
Yes
No
Daily commute in ONE WAY miles:
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:
VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:
Make & Model:
VEHICLE #1 COVERAGES:
Limits of Bodily Injury Liability:
$25/50 BI / 25 PD
$50/100 BI / 50 PD
$100/300 BI / 100 PD
$250/500 BI / 100 PD
Comprehensive Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Collision Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists Same Limits as Bodily Injury Liability?
YES
NO
Rental Car & Towing Coverage?
YES
NO
Medical Coverage?
YES
NO
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
VEHICLE #2 COVERAGES:
Limits of Bodily Injury Liability:
$25/50 BI / 25 PD
$50/100 BI / 50 PD
$100/300 BI / 100 PD
$250/500 BI / 100 PD
Comprehensive Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Collision Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists Same Limits as Bodily Injury Liability?
YES
NO
Rental Car & Towing Coverage?
YES
NO
Medical Coverage?
YES
NO
If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:
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