VEHICLE INFORMATION

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Year

Make

Model

I.D. #

Vehicle Use

Pleasure Work < 3 mi. Work < 10 mi Work > 10 mi Business

Pleasure Work < 3 mi. Work < 10 mi Work > 10 mi Business

Pleasure Work < 3 mi. Work < 10 mi Work > 10 mi Business

Pleasure Work < 3 mi. Work < 10 mi Work > 10 mi Business

Miles Driven Each Year

Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+

Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+

Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+

Under 5,000 5,000-9,999 10,000-14,999 15,000-19,999 20,000-24,999 30,000-34,999 35,000-39,999 40,000-44,999 45,000-49,999 50,000+

Ownership

Leased Paid-Off Financed

Leased Paid-Off Financed

Leased Paid-Off Financed

Leased Paid-Off Financed

DRIVER INFORMATION

Driver One

Driver Two

Driver Three

Driver Four

Full Name

Birthdate

Sex

Male Female

Male Female

Male Female

Male Female

Marital Status

Single Married Divorced Widowed Separated

Single Married Divorced Widowed Separated

Single Married Divorced Widowed Separated

Single Married Divorced Widowed Separated

Yrs Licensed

State Licensed

Operator Number

VIOLATION INFORMATION

Last 3 Yrs (Minors)
Last 5 Yrs (Majors)

Driver 1

Driver 2

Driver 3

Driver 4

Minor Violations - Speeding,
Turn, Stop Sign, Red Light, etc.

None  1  2  3  4 

None  1  2  3  4 

None  1  2  3  4 

None  1  2  3  4 

Accidents - Non Chargeable

None  1  2  3  4 

None  1  2  3  4 

None  1  2  3  4 

None  1  2  3  4 

Accidents - Chargeable

None  1  2  3  4 

None  1  2  3  4 

None  1  2  3  4 

None  1  2  3  4 

Major Violations - Drunk Driving,
Reckless, Hit & Run, etc.

None  1  2  3  4 

None  1  2  3  4 

None  1  2  3  4 

None  1  2  3  4 

DEDUCTIBLE INFORMATION

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Comprehensive (Theft)

100 250 500 1,000

100 250 500 1,000

100 250 500 1,000

100 250 500 1,000

Collision

250 500 1,000

250 500 1,000

250 500 1,000

250 500 1,000

ADDITIONAL COVERAGE

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Towing & Labor

50 100 None

50 100 None

50 100 None

50 100 None

Rental Reimbursement

$15/$450 $30/$900 None

$15/$450 $30/$900 None

$15/$450 $30/$900 None

$15/$450 $30/$900 None

SAFETY FEATURES

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Passive Restraint

1 Air Bag 2 Air Bags Auto Seatbelts None

1 Air Bag 2 Air Bags Auto Seatbelts None

1 Air Bag 2 Air Bags Auto Seatbelts None

1 Air Bag 2 Air Bags Auto Seatbelts None

Anti-Theft

Yes No

Yes No

Yes No

Yes No

ABS Brakes

Yes No

Yes No

Yes No

Yes No