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and fleet accounts SAVE MONEY
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DRIVER INFORMATION
#1
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Cycle Safety Course?
# Years U.S. Cycle License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations 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:
Cycle Safety Course?
# Years U.S. Cycle License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
VEHICLE #1
INFORMATION
Year of vehicle:
Make & Model:
Is this a 4 Wheeler?:
If Yes, Describe:
Annual Mileage:
# of CC's:
Value of Bike:
$
Special Equipment Value:
$
VEHICLE #1
COVERAGES:
Select Liability Limits
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists Cov.?
Yes
No
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Is this a 4 Wheeler?:
If Yes, Describe:
Annual Mileage:
# of CC's:
Value of Bike:
$
Special Equipment Value:
$
VEHICLE #2
COVERAGES:
Limits of Liability:
(Limits Must be the Same as Cycle #1)
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists Cov.?
Yes
No
Send my quotation via:
E-Mail Fax Regular Mail
Call Me by Phone
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Five Star Insurance Agency | 2093 Rock Chapel Road | Lithonia, GA 30058 | Toll Free: 866-740-4132 | Local: 678-526-7979 | Fax: 678-526-7222
