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Current Carrier Information and Expiration date of policy? Insurance Company Name: Expiration date: Coverage Information..... Liability Limit per Accident $ 15,000 per Person/30,000 per Accident Bodily Injury/10,000 Property Damage per accident 25,000 per Person/$ 50,000 per Accident Bodily Injury/10,000 Property Damage per accident $ 25,000 per Person/50,000 per Accident Bodily Injury/15,000 Property Damage per accident 50,000 per Person/$ 100,000 per Accident Bodily Injury/25,000 Property Damage per accident $ 100,000 per Person/300,000 per Accident Bodily Injury/50,000 Property Damage per accident 250,000 per Person/$ 500,000 per Accident Bodily Injury/100,000 Property Damage per accident $ 35,000 per accident (Bodily Injury & Property Damage) $ 50,000 per accident (Bodily Injury & Property Damage) $ 100,000 per accident (Bodily Injury & Property Damage) $ 200,000 per accident (Bodily Injury & Property Damage) $ 300,000 per accident (Bodily Injury & Property Damage) $ 500,000 per accident (Bodily Injury & Property Damage) $ 750,000 per accident (Bodily Injury & Property Damage) $ 1,000,000 per accident (Bodily Injury & Property Damage) $ 1,500,000 per accident (Bodily Injury & Property Damage) Un & Underinsured Motorist Limit Rejected $ 15,000 per Person/30,000 per Accident $ 25,000 per Person/50,000 per Accident $ 50,000 per Person/100,000 per Accident $ 100,000 per Person/300,000 per Accident $ 250,000 per Person/500,000 per Accident $ 35,000 per accident $ 50,000 per accident $ 100,000 per accident $ 200,000 per accident $ 300,000 per accident $ 500,000 per accident $ 750,000 per accident $ 1,000,000 per accident Pennsylvania First Party Benefits Medical Expenses $ 5,000 per person $ 10,000 per person $ 25,000 per person $ 50,000 per person $ 100,000 per person Extraordinary Medical Expenses rejected $ 100,000 $ 300,000 $ 500,000 $ 1,000,000 (Extraordinary Medical Benefits covers medical expenses over 100,000) Work Loss Benefits rejected $ 1,000 per month/5,000 max $ 1,000 per month/15,000 max $ 1,500 per month/$ 25,000 max $ 2,500 per month/50,000 max Funeral Expenses rejected $ 1,500 per person 2,500 per person Accidental Death Benefits rejected $ 5,000 per person $ 10,000 per person $ 25,000 per person OR Combined Benefits Per Person Limit: (Medical Expenses & Work Loss Benefits/Funeral Expenses/Accident Death Benefit) n/a $ 50,000/2,500 funeral expenses/10,000 accidental death $ 100,000/2,500 funeral expenses/10,000 accidental death $ 177,500/2,500 funeral expenses/25,000 accidental death $ 277,500/2,500 funeral expenses/25,000 accidental death Vehicle Information Vehicle # 1 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 2 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 3 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 4 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 5 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 6 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 7 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years...... DATE DRIVER NAME TYPE OF OCCURRENCE NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed You can also fax this completed form to 1-888-800-0034
Coverage Information.....
Vehicle Information
Vehicle # 1 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 2 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 3 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 4 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 5 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 6 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 7 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years...... DATE DRIVER NAME TYPE OF OCCURRENCE NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed You can also fax this completed form to 1-888-800-0034
Vehicle # 2 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 3 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 4 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 5 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 6 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 7 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years...... DATE DRIVER NAME TYPE OF OCCURRENCE NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed You can also fax this completed form to 1-888-800-0034
Vehicle # 3 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 4 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 5 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 6 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 7 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years...... DATE DRIVER NAME TYPE OF OCCURRENCE NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed You can also fax this completed form to 1-888-800-0034
Vehicle # 4 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 5 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 6 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 7 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years...... DATE DRIVER NAME TYPE OF OCCURRENCE NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed You can also fax this completed form to 1-888-800-0034
Vehicle # 5 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 6 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 7 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years...... DATE DRIVER NAME TYPE OF OCCURRENCE NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed You can also fax this completed form to 1-888-800-0034
Vehicle # 6 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 7 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years...... DATE DRIVER NAME TYPE OF OCCURRENCE NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed You can also fax this completed form to 1-888-800-0034
Vehicle # 7 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years...... DATE DRIVER NAME TYPE OF OCCURRENCE NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed NONE Accident: At Fault: Less than $950 Accident: At Fault: More than $949 Accident: Not At-fault A.R.D. Enrollment At Fault Accident Careless Driving Comprehensive Claim: Not Glass Breakage under $1,000 Comprehensive Claim: Not Glass Breakage over $1,000 Comprehensive Claim: Glass Breakage Only Displaying Foreign License During Suspension Drag Racing Driving with a Suspended/Revoked License Driving Left of Center Driving on Left Side of Highway Driving Too Fast For Conditions Driving Without Lights to Avoid Arrest Driving Without a License DUI or DWI Eluding an Officer Failure to Give Information, and Render Aid Failure to Submit to Alcohol/Drug Test Failure to Yield Felony with a Vehicle Felony theft of vehicle Filing due to point total Filing due to Violation Fleeing from police Following too closely Hit & Run involving death or injury Hit & Run involving attended vehicle Homicide with a vehicle Illegal/Improper Passing Improper Backing Improper Passing Improper Turn Leaving the Accident: Property Damage Only Leaving the Accident: Bodily Injury Non-Vehicle Felony Open Bottle Operate without consent Operating Vehicle After Registration Suspended Passing a School Bus Permitting use of an Unauthorized Vehicle Permitting an Unauthorized Person to Drive Racing on Highways including drag racing Reckless Driving Revoked License due to Violation Speeding: under 15 mph over limit Speeding: 15 mph or over limit Speeding: with Injury Stop sign/traffic light Suspended License due to Violation Trespass by Motor Vehicle Wrong Way All Other Not Listed You can also fax this completed form to 1-888-800-0034
Vehicle # 8 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No If YES, Please list ALL accidents and violations within last 3 years......
Vehicle # 9 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No
Vehicle # 10 USE: Service (to 1 to 3 jobsites per day) Commercial (general business use) Retail/Delivery Use Business & Personal Use Year Make & Model/# Passenger VIN # Current Value/Worth Cost New CompDed CollDed $ $ n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 n/a $ 100 $ 200 $ 250 $ 500 $ 750 $ 1,000 $ 1,500 $ 2,500 Radius of Operation: Local: 0 - 50 miles Intermediate: 51 - 200 miles Long Distance: over 200 miles Gross Vehicle Weight: Driver Information Driver Name Birth License# Years Licensed Sex MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale MaleFemale ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No
Driver Information
ACCIDENTS & VIOLATIONS Does any driver have any accidents or violations? Yes No
If YES, Please list ALL accidents and violations within last 3 years......
You can also fax this completed form to 1-888-800-0034
M c G R A T H I N S U R A N C E G R O U P 4170 William Penn Highway, Murrysville, PA. 15668-1890 (724) 327-8474 (FAX) 327-7911 Toll Free: 1-800-977-2999 Fax: 1-888-800-0034 www.McGrathInsuranceGroup.com Jim@McGrathInsuranceGroup.com
www.McGrathInsuranceGroup.com Jim@McGrathInsuranceGroup.com