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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