DRIVER INFORMATION List All Accidents and Moving Violations in Last Three Years.
DRIVER NUMBER 1
Driver Name
M/F
D.O.B.
Drivers Lic.
Yr. 1st Licensed
Has driver completed a Mature Driver Training Course? Date completed
% of Vehicle Use
Accident
Violation
Veh. 1
Veh. 2
Veh. 3
Date
Your Fault?
Injuries?
Date
Type
DRIVER NUMBER 2
Driver Name
M/F
D.O.B.
Drivers Lic.
Yr. 1st Licensed
Has driver completed a Mature Driver Training Course? Date completed
% of Vehicle Use
Accident
Violation
Veh. 1
Veh. 2
Veh. 3
Date
Your Fault?
Injuries?
Date
Type
VEHICLE NUMBER ONE INFORMATION
Year
Make
Model
Annual Mileage
Airbags
Alarm
Vehicle ID No.
VEHICLE NUMBER TWO INFORMATION
Year
Make
Model
Annual Mileage
Airbags
Alarm
Vehicle ID No.
COVERAGES
Bodily Injury
Other $
Property Damage
Other $
Excess Medical Payments
Other $
Uninsured/Underinsured Motorist
Other $
Vehicle#
Comprehensive Deductible
Collision Deductible
UMPD
Rental Coverage
Towing Coverage
1
2
3
4
The information contained here is general in nature, and cannot cover all circumstances or policies. For specific information, please refer to the actual policies, or contact us and we'll be happy to help. You can reach Garcia & Associates Insurance at 1-800-350-9207 or via E-mail at info@garciainsurance.com.
