Personal Information
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Address (cont.)
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Information About Your Driver
Driver #1
Name
Relation to you
Date of Birth xx/xx/xx
Sex
Martial Status
License #
Date First Licensed xx/xx/xxx
Is this a student over 100 miles away, without a car?
Driver #2
Name
Relation to you
Date of Birth xx/xx/xx
Sex
Martial Status
License #
Date First Licensed xx/xx/xxx
Is this a student over 100 miles away, without a car?
Driver #3
Name
Relation to you
Date of Birth xx/xx/xx
Sex
Martial Status
License #
Date First Licensed xx/xx/xxx
Is this a student over 100 miles away, without a car?
Information About Your Coverages
Comprehensive
Deductible Vehicle 1: (if applicable) $50 F/Glass $100 F/Glass $200 F/Glass No Deductible
Deductible Vehicle 2: (if applicable) $50 F/Glass $100 F/Glass $200 F/Glass No Deductible
Deductible Vehicle 3: (if applicable) $50 F/Glass $100 F/Glass $200 F/Glass No Deductible
Liability choose one... $25k/$50k/$10k Split Limits $50k/$100k/$25k Split Limits $100k/$300k/$50k Split Limits $250k/$500k/$100k Split Limits $50k Single Limit $100k Single Limit $300k Single Limit $500k Single Limit
Collision
Deductible Vehicle 1: (if applicable) $250 $500 $1000 No Deductible
Deductible Vehicle 2: (if applicable) $250 $500 $1000 No Deductible
Deductible Vehicle 3: (if applicable) $250 $500 $1000 No Deductible
Information About Your Driving Record
Has any driver in your household had a traffic violation, accident (whether or not at fault) or had a license suspended or revoked in the past five(5) years?
Have all drivers under 21 years completed a drivers' safety course?
Any fire, theft of vandalism losses in the past three (3) years? (Be as specific as possible so we may expedite your request.)
Have any drivers completed an accredited defensive driving course in the past three (3) years?
Have you or a household member had a foreclosure, repossession, bankruptcy, judgement or lien in the past 5 years?
Please explain Yes answers here:
