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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