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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 violations last 3 years:
Number & Type of MAJOR violations 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 violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
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 ID# (for rating accuracy):
Annual Mileage:
Used in business? (Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
Select Comprehensive Deductible:
Select Collision Deductible:
Uninsured Motorists Coverage?
YES
NO
Rental Car & Towing Coverage?
YES
NO
Medical and/or PIP Coverage?
YES
NO
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Annual Mileage:
Used in business? (Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits
- - - Liability Limits Must Match Vehicle #1 - - -
Select Comprehensive Deductible:
Select Collision Deductible:
Uninsured Motorists Coverage?
YES
NO
Rental Car & Towing Coverage?
YES
NO
Medical and/or PIP Coverage?
YES
NO
Comments or Remarks:
(List additional drivers, autos, etc. here)
If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records here:
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Phone: (717) 520-9107