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Drivers Information
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Violation Information
Last 3 years (minor violations) / Last 5 years (major violations)
Minor Violations - speeding, turn, stop sign, red light, etc.
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Accidents - non chargeable
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Add/Change Vehicle Information
Year
Make
Model
Vin #
Miles per Year
Where Parked at Night
Airbag (drivers)
Yes
No
Airbag (driver & passenger)
Yes
No
Side Airbags (driver & passenger)
Yes
No
Anti-Theft Device
Yes
No
Smart Technology
Yes
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Ownership
Deductible Information
Comp (theft)
None
$250
$500
$1000
$1500
$2000
Collision
None
$250
$500
$1000
$1500
$2000
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Coverage Information
Personal Liability / Bodily Injury
$15,000/30,000
$25,000/50,000
$30,000/60,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
Personal Liability / Property Damage
$5,000
$10,000
$25,000
$50,000
$100,000
Uninsured Motorist / Bodily Injury
No Coverage
$15,000/30,000
$25,000/50,000
$30,000/60,000
$50,000/100,000
$100,000/300,000
$250,000/500,000
Uninsured Motorist / Property Damage
No Coverage
$3500
Deductible Waiver
Medical Payment
None
$1000
$2000
$2500
$5000
$10,000
$15,000
$20,000
$25,000
$50,000
$100,000
Miscellaneous Information
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Expiration Date (DD/MM/YYYY)
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