Number of Vehicles: |
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Number of Drivers: |
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***YOUR VEHICLE TO DRIVE RATIO EXCEEDS ACCEPTABLE GUIDELINES***
PLEASE
EXPLAIN IN THE COMMENTS SECTION |
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Name: |
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Street Address:
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Town:
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State:
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ZIP:
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Primary Insured's Social Security Number: |
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Do you own a home? |
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Who is your homeowners insurance carrier ? |
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When do you need it? |
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Do you have insurance now?
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If Yes, when does it expire? |
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If No, please choose a reason: |
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COVERAGES: |
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Liability Limits: |
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Tort Threshold: |
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VEHICLE #1: |
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Vehicle Manufacturer:
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Vehicle Model ( Include Model # ):
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Vehicle Year: |
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Vehicle Type:
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2 Door
Automobile or SUV
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4
Door Automobile or SUV |
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2
Door Truck w/Standard Cab |
2
Door Truck w/Extd Cab |
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3
Door Truck |
4
Door Truck/Quad Cab |
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Vehicle V.I.N. Number: |
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How many miles are on this vehicle? |
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How many miles is this vehicle driven per year? |
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Vehicle Options, Safety Equipment, Etc: |
4
Wheel or All Wheel Drive |
Driver's
Side Air Bag |
(Check All That Apply) |
Passenger
Air Bag |
Side
Curtain Air Bags |
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Auto-Retract
Seat Belts |
Anti-Lock
Brakes |
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Anti-Theft
System |
Lo-Jack
or On-Star |
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Comprehensive Deductible: |
No
Coverage Desired |
$100
Deductible |
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$250
Deductible |
$500
Deductible |
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$750
Deductible |
$1,000
Deductible |
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Collision Deductible: |
No
Coverage Desired |
$100
Deductible |
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$250
Deductible |
$500
Deductible |
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$750
Deductible |
$1,000
Deductible |
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Towing? |
Yes |
No |
Rental? |
Yes |
No |
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Vehicle Usage (One Way Miles): |
Pleasure |
Drive
to Work Under 3 Miles |
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Drive
to Work Under 10 Miles |
Drive
to Work Over 10 Miles |
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Business
Use |
Artisan/Contractor |
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DRIVER INFORMATION: |
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Driver Name: |
Date of Birth |
Sex |
Marital Status |
Driver's Ed |
Good Student |
Vehicle Driven |
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M
F |
Single |
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Vehicle #1 |
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Married |
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Divorced
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Separated
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M
F |
Single |
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Vehicle #1 |
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Married |
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Divorced
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Separated
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M
F |
Single |
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Vehicle #1 |
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Married |
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Divorced
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Separated
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Are there any other licensed drivers living in the house not
covered under another policy? If so, please indicate such and list
their name, DOB, & Sex. |
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Do any drivers under this policy or any other policy in the
house have any tickets, DWI's, at-fault accidents, or non-at fault
accidents within the past 5 years? If so, please list the driver and
what happened. |
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COMMENTS: |
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Contact's Phone Number (Include Area Code): |
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Contact's Fax Number (Include Area Code):
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Contact's E-Mail Address:
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