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:
Rate Your Credit
History: (Many
companies use credit to adjust your price.)
Superior
Excellent
Fair
Poor
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:
<
Rate this Driver's Credit
History: (Many
companies use credit for pricing.)
Superior
Excellent
Fair
Poor
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 Number
(If Available):
Vehicle
Use:
To/From Work
Pleasure Only
Business Use
Annual Mileage:
VEHICLE #1 COVERAGES:
Limits of
Liability:
$25/50 BI / 25 PD
$50/100 BI / 50 PD
$100/300 BI / 100 PD
$250/500 BI / 100 PD
$1 Million + (Quote Umbrella)
Uninsured/Under
Insured Motorist Coverage?
YES
NO
If you select "Yes" limits will
be the same as Liability above.
Personal Injury
Protection (PIP)
or Medical Payments?
PIP
Med Pay
None
=>
If you selected PIP or Med Pay select limits below
Limits of
PIP or Medical Payments:
$2,500
$5,000
$10,000
$25,000
$50,000
None
Comprehensive
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Collision
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Rental Car &
Towing Coverage?
YES
NO
VEHICLE #2 INFORMATION (if
none, leave blank)
Year of Vehicle:
Make & Model:
Vehicle ID Number
(If Available):
Vehicle
Use:
To/From Work
Pleasure Only
Business Use
Annual Mileage:
VEHICLE #2 COVERAGES:
Liability, Uninsured/Under
Insured Motorist
and PIP/Med Pay choices must
all be the same as Vehicle 1.
Comprehensive
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Collision
Coverage:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Rental Car &
Towing Coverage?
YES
NO
Select Driver
for this Vehicle
Driver #1
Driver #2
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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