Number, Type and approximate dates of all ACCIDENTS in the last 3 years. (You must list if an accident was At-Fault or Not-At-Fault. If At-Fault, advise if anyone claimed an injury or not. Insurance carriers require documentation of Non-fault or No-Injury.)
Number, Type and appoximate dates of all MINOR TICKETS in last 3 years: (Examples include: speeding, failure to stop, turn violation.)
Number & Type of MAJOR VIOLATIONS in the last 3 years: (examples include: DUI (no injury or w/ injury), Reckless Driving, Caught Driving on a Suspended License, Hit and Run)
One way miles from home to work:
Once at work, do you use your vehicle for business?
Yes
No
(if yes, please explain how you use your vehicle for business including: occupation and jobsites/locations per day)
Does Driver need an SR22 FILING?
Yes
No
DRIVER #2 INFORMATION
Full Name:
Birthdate:
Sex:
Age 1st Licensed
Number, Type and approximate dates of all ACCIDENTS in the last 3 years. (You must list if an accident was At-Fault or Not-At-Fault. If At-Fault, advise if anyone claimed an injury or not. Insurance carriers require documentation of Non-fault or No-Injury.)
Number, Type and appoximate dates of all MINOR TICKETS in last 3 years: (Examples include: speeding, failure to stop, turn violation.)
Number & Type of MAJOR VIOLATIONS in the last 3 years: (examples include: DUI (no injury or w/ injury), Reckless Driving, Caught Driving on a Suspended License, Hit and Run)
One way miles from home to work:
Once at work, do you use your vehicle for business?
Yes
No
(if yes, please explain how you use your vehicle for business including: occupation and jobsites/locations per day)
Does Driver need an SR22 FILING?
Yes
No
VEHICLE #1 INFORMATION
Year of vehicle:
Make:
Model:
Make & Model:
Make & Model:
Vehicle ID (V.I.N.# for rating accuracy):
Annual Mileage:
VEHICLE #1 COVERAGES:
Limits of Liability:
$15/30 BI / 5 PD(Minimum required by law)
$25/50 BI / 25 PD
$50/100 BI / 25 PD
$100/300 BI / 50 PD
Higher limits of liability are available upon request.
Comprehensive Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Collision Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists Coverage?
YES
NO
Rental Car & Towing Coverage?
YES
NO
Medical Payments Coverage?
YES
NO
VEHICLE #2 INFORMATION
Year of vehicle:
Make:
Model:
Make & Model:
Make & Model:
Vehicle ID (V.I.N.# for rating accuracy):
Annual Mileage:
VEHICLE #2 COVERAGES:
Limits of
Liability:
$15/30 BI / 5 PD(Minimum required by law)
$25/50 BI / 25 PD
$50/100 BI / 25 PD
$100/300 BI / 50 PD
Higher limits of liability are available upon request.
Comprehensive
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Collision
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Uninsured Motorists
Coverage?
YES
NO
Rental Car &
Towing Coverage?
YES
NO
Medical Payments Coverage?
YES
NO
Comments or Remarks:
(List additional drivers, autos, etc. here)
If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:
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