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DRIVER INFORMATION #1
Name:
Birthdate:
Sex (M/F):
# Years U.S. Licensing:
Drivers License #: (optional - may help get additional discounts):
Be specific about if accidents are "at-fault" or "NOT-at-fault" ;
Number & Type of Accidents last 3 years:
Number & Type of MINOR Violations last 3 years:
Number & Type of MAJOR Violations (DUI, etc.) last 3 years:
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Licensing:
Drivers License #: (optional - may help get additional discounts):
Be specific about if accidents are "at-fault" or "NOT-at-fault"
Number & Type of Accidents last 3 years:
Number & Type of MINOR Violations last 3 years:
Number MAJOR Violations (DUI, etc.) last 3 years:
Describe Violations here:
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:
VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Used in business? (Explain, if yes):
VEHICLE #1 COVERAGES:
Select Liability Limits
Select Comprehensive Deductible:
Select Collision Deductible:
Uninsured Motorists Coverage?
YES
NO
Rental Car & Towing Coverage?
YES
NO
Medical and/or PIP Coverage?
YES
NO
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Vehicle ID# (for rating accuracy):
Used in business? (Explain, if yes):
VEHICLE #2 COVERAGES:
Select Liability Limits
- - - Liability Limits Must Match Vehicle #1 - - -
Select Comprehensive Deductible:
Select Collision Deductible:
Uninsured Motorists Coverage?
YES
NO
Rental Car & Towing Coverage?
YES
NO
Medical and/or PIP Coverage?
YES
NO
If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records here:
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Look At These REAL LIFE Rate Examples of Recent Car Insurance Houston Accounts We Have Placed:
30 Year Old Male, with a 2004 Honda Civic LX; Basic Liability coverage for only $39.50 a MONTH!
35 Year Old Driver in Spring, Texas:
35 year Old Male, with Full Coverage ($500 deductible comp and collision) for 2005 Saturn Ion; only $78.39 a MONTH!
Couple in Katy, TX. Male 30 years old and Female 25 years old:
Male 30 years old and Female 25 years old on a 2007 Chevy Tahoe and a 2004 Ford F150 supercab; Full coverage ($500 deductible comp and collision) for only $129.66 a MONTH!
