Be specific to tell if
accidents are "at-fault" or "NOT-at-fault" -
(carriers require proof on NOT-at-fault
accidents); Also, be specific as to TYPE of
violations, and approximate DATES of each in the
fields below:
Number & Type of Accidents last 3
years:
Number & Type of MINOR violations last
3 years:
Number & Type of MAJOR violations last
3 years:
Daily commute in ONE WAY
miles:
Does
Driver need an SR22 FILING?
Yes No
Minnesota Drivers License #:
DRIVER
INFORMATION #2 (if none, leave
blank)
Name:
Birthdate:
Sex:
Social Security #:
Be specific to tell if
accidents are "at-fault" or "NOT-at-fault" -
(carriers require proof on NOT-at-fault
accidents); Also, be specific as to TYPE of
violations in fields below:
Number & Type of Accidents last 3
years:
Number & Type of MINOR violations last
3 years:
Number & Type of MAJOR violations last
3 years:
Daily commute in ONE WAY
miles:
Does
Driver need an SR22 FILING?
Yes No
Minnesota Drivers License #:
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):
Annual Mileage:
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):
Annual Mileage:
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
Comments or Remarks: (List
additional drivers, autos, etc. here)
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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