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    General Information

    Please Tell Us About The Vehicle You Drive

    Vehicle 1:

    Primary Usage:-

    Where Is The Car Parked Overnight? :-

    Vehicle 2:

    Primary Usage:-

    Where Is The Car Parked Overnight? :-

    Current Insurance Information (if applicable):

    Driver's Information

    Driver 1:


    Marital Status

    Driver 2:


    Marital Status

    Accidents / Violations In Last 5 Years

    (Driver 1)

    (Driver 2)

    Minor Violations - Speeding, Turn, Stop Sign, Red Light, etc.:

    Accidents - Non Chargeable:

    Accidents - Chargeable:

    Chargeable Accident Cost ($):

    Major Violations - Drunk driving, Reckless, Hit And Run, etc.:


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