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CONTACT INFORMATION
Name:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Home tel:
Work tel:
Cell:
e-mail:
EMPLOYMENT INFORMATION
Occupation:
Employer Name:
Employer Address:
Length of Employment:
CURRENT INSURANCE INFORMATION
Present Insurance Name:
Expiration of Policy:
Company Car?
Yes
No
Own Home?
Yes
No
Resident of California
12 months or more?
Yes
No
Continuous Insurance
Last 36 months?
Yes
No
VEHICLE INFORMATION
Vehicle #1
Year:
Make:
Model:
VIN:
Annual Mileage:
Miles to Work:
Odometer:
Alternate Garage Zip Code:
Comprehensive:
-----------------------
100
200
250
500
1000
Collision:
-----------------------
100
200
250
500
1000
Towing:
Yes
No
Rental Reimbursement:
Yes
No
Vehicle #2
Year:
Make:
Model:
VIN:
Annual Mileage:
Miles to Work:
Odometer:
Alternate Garage Zip Code:
Comprehensive:
-----------------------
100
200
250
500
1000
Collision:
-----------------------
100
200
250
500
1000
Towing:
Yes
No
Rental Reimbursement:
Yes
No
Vehicle #3
Year:
Make:
Model:
VIN:
Annual Mileage:
Miles to Work:
Odometer:
Alternate Garage Zip Code:
Comprehensive:
-----------------------
100
200
250
500
1000
Collision:
-----------------------
100
200
250
500
1000
Towing:
Yes
No
Rental Reimbursement:
Yes
No
Vehicle #4
Year:
Make:
Model:
VIN:
Annual Mileage:
Miles to Work:
Odometer:
Alternate Garage Zip Code:
Comprehensive:
-----------------------
100
200
250
500
1000
Collision:
-----------------------
100
200
250
500
1000
Towing:
Yes
No
Rental Reimbursement:
Yes
No
Coverages:
BI/PD Liability:
-----------------------
15000/30000
25000/50000
30000/60000
50000/100000
100000/300000
250000/500000
500000/500000
UM/UIM:
-----------------------
15000/30000
25000/50000
30000/60000
50000/100000
100000/300000
250000/500000
500000/500000
UMPD:
-----------------------
5000
10000
15000
25000
50000
100000
250000
Medical:
-----------------------
500
1000
2000
5000
10000
25000
DRIVER INFORMATION
Driver #1
Sex:
Male
Female
Marital Status:
Married
Single
DOB:
Driver L.#:
Drives/Operates:
Vehicle #1:
Yes
No
Vehicle #2:
Yes
No
Vehicle #3:
Yes
No
Vehicle #4:
Yes
No
Accidents/Violations
1.
Date:
2.
Date:
3.
Date:
Driver #2
Sex:
Male
Female
Marital Status:
Married
Single
DOB:
Driver L.#:
Drives/Operates:
Vehicle #1:
Yes
No
Vehicle #2:
Yes
No
Vehicle #3:
Yes
No
Vehicle #4:
Yes
No
Accidents/Violations
1.
Date:
2.
Date:
3.
Date:
Driver #3
Sex:
Male
Female
Marital Status:
Married
Single
DOB:
Driver L.#:
Drives/Operates:
Vehicle #1:
Yes
No
Vehicle #2:
Yes
No
Vehicle #3:
Yes
No
Vehicle #4:
Yes
No
Accidents/Violations
1.
Date:
2.
Date:
3.
Date:
Driver #4
Sex:
Male
Female
Marital Status:
Married
Single
DOB:
Driver L.#:
Drives/Operates:
Vehicle #1:
Yes
No
Vehicle #2:
Yes
No
Vehicle #3:
Yes
No
Vehicle #4:
Yes
No
Accidents/Violations
1.
Date:
2.
Date:
3.
Date:
Lic. OE75446
E Summers Insurance Agency, Copyright 2005.
ALL RIGHTS RESERVED.
