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(This Page Last Updated on October 20, 2005)
DRIVER INFORMATION
#1
(if more than two drivers, list in remarks)
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR Cites within last 3 years:
Number & Type of MAJOR Cites within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
DRIVER INFORMATION
#2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR Cites within last 3 years:
Number & Type of MAJOR Cites within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
LIMOUSINE - VEHICLE #1: If more than 2 vehicles, list in remarks or CALL US Toll Free at: 866-722-7861
Year of vehicle:
Make & Model:
Type (stretch, etc.):
Length in Feet:
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
LIMOUSINE - VEHICLE #1
COVERAGES:
Limits of Liability:
$15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 25
PD
$100/300 BI / 50
PD
$250/500 BI / 100
PD
$1 Million
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
LIMOUSINE - VEHICLE #2:
Year of vehicle:
Make & Model:
Type (stretch, etc.):
Length in Feet:
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
LIMOUSINE - VEHICLE #2
COVERAGES:
Limits of Liability:
$15/30 BI / 10 PD
$25/50 BI / 15 PD
$50/100 BI / 25
PD
$100/300 BI / 50
PD
$250/500 BI / 100
PD
$1 Million
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
Send my quotation via:
E-Mail Fax Regular Mail
Call Me by Phone
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