Have you ever been cited for OR arrested for ORconvicted of any traffic
ticket (infraction, misdemeanor or felony) in the past in any state (regardless
of whether charges were filed or not against you):
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Yes
No
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If yes, describe date of citation OR arrest (month, day, year), county/state of citation OR arrest and charge(s):
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Was/were the conviction(s) a misdemeanor or felony? Please explain:
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Have you had any accidents or claims in the past 3 years? |
Yes
No
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Please explain |
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Do you own a vehicle? |
Yes
No
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Vehicle Year |
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Make |
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Model |
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Primary Use |
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Daily Mileage (one-way) |
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Annual Mileage |
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Is the vehicle garaged? |
Yes
No
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Is this car equipped with an alarm or a tracking device? |
Yes
No
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Do you currently have insurance? |
Yes
No
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Current Insurance Company |
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Current policy expiration date (MM/YYYY) |
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How long have you had auto insurance? |
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How long have you been a customer? |
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Have you filed for bankruptcy in the past 5 years? |
Yes
No
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Add an additional driver? |
Yes
No
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Please explain: name (first, last) and date of birth and license number of person(s)
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Add an additional vehicle?? |
Yes
No
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Please explain: make/model/year of vehicle(s) plus who is owner of vehicle
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