| Today's date (MM/DD/YYYY) * |
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| First Name * |
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| Last Name * |
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| Address * |
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| City * |
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| Zip * |
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| Home phone number * |
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| Work phone number |
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| Do you * |
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| Date of birth (MM/DD/YYYY) * |
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| Occupation * |
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| Number of years licensed in CA * |
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| Number of years licensed in USA * |
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| Additional drivers you would like included in the quote (name, relation, date of birth, occupation, years as licensed driver (in CA and USA) and years as a resident (in CA and USA) |
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| Has any driver had a driver's license suspended or revoked in the last three years? * |
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| Has any driver had a restricted or expired driver's license? * |
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| Has any driver been convicted for any moving traffic violations in the last three years? * |
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| Has any driver ever been convicted for driving while drinking, open bottle, possession of alcohol, drunk in auto, drunk in public, hit and run, reckless driving or refusal to submit to intoximeter test? * |
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| Has any driver been involved in an accident in the last three years? * |
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| Was insured automobile lawfully parked? |
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| Was insured automobile struck in rear while lawfully stopped at a signal? |
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| Has any driver had a motor vehicle stolen during the last five years? * |
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| Has any driver had any other losses paid by your insurance company in the past five years? * |
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| Please explain any YES answers (provide dates of each conviction or accident, name of driver involved and details) |
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| Vehicle #1 (Please include year, make, model, number of doors, number of cylenders, original cost or current value, miles driven one way to work/school, miles driver per year, business or personal use, principal driver's name and owner's name) * |
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| Vehicle #2 (Please include year, make, model, number of doors, number of cylenders, original cost or current value, miles driven one way to work/school, miles driver per year, business or personal use, principal driver's name and owner's name) |
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| Vehicle #3 (Please include year, make, model, number of doors, number of cylenders, original cost or current value, miles driven one way to work/school, miles driver per year, business or personal use, principal driver's name and owner's name) |
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| Vehicle #3 (Please include year, make, model, number of doors, number of cylenders, original cost or current value, miles driven one way to work/school, miles driver per year, business or personal use, principal driver's name and owner's name) |
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| Vehicle #4 (Please include year, make, model, number of doors, number of cylenders, original cost or current value, miles driven one way to work/school, miles driver per year, business or personal use, principal driver's name and owner's name) |
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| If youthful driver is a full time student, is grade average "B" or better? |
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| If yes, name(s) of driver(s) |
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| If driver is 55+, does the driver have a MATURE DRIVER CERTIFICATE? |
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| If yes, name(s) of driver(s) |
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| List any other persons in household over age twelve (not listed above) |
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| BODILY INJURY LIABILITY * |
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| PROPERTY DAMAGE LIABILITY * |
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| UNINSURED MOTORIST - BODILY INJURY * |
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| Is UNINSURED MOTORIST - PROPERTY DAMAGE coverage desired? * |
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| MEDICAL PAYMENTS * |
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| Is COMPREHENSIVE COVERAGE desired? * |
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| Is COLLISION coverage desired? * |
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| Is COLLISION RENTAL CAR BENEFIT coverage desired? * |
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| Verification: |
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