Stephen B. Groton -- Insurance Agent and Broker CA License Number 0816642 626-584-6303
DRIVER INFORMATION #1 (if more than two drivers, list in remarks)
Name:
Birthdate:
Sex:
# Years U.S.
Auto License:
Date of Hire:
State & License#:
Number & Type of
Accidents within
last 3 years:
Number & Type of
MINOR Citations
in last 3 years:
Number & Type of
MAJOR Citations
in last 3 years:
Radius of Operation
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:
Date of Hire:
State & License#:
Number & Type of
Accidents within
last 3 years:
Number & Type of
MINOR Citations
in last 3 years:
Number & Type of
MAJOR Citations
in last 3 years:
Radius of Operation
in ONE WAY miles:
Does Driver need
an SR22 FILING?
Yes No
Comments or
Remarks?
COMMERCIAL VEHICLE #1: If more than 2 vehicles, list in remarks:
Year of vehicle:
Make & Model:
Type (long haul trailer/tractor, tow-truck, bobtail, etc., etc.):
Length in Feet:
Radius of operation:
Value $:
List Special Coverages Needed, or Special Equipment to be covered:
VEHICLE #1 COVERAGES:
Limits of
Bodily Injury Liability:
State Required Limits Please
$1 Million
$750,000
$500,000 $300,000
$100,000
$60,000
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
Do you want PIP /
Medical Coverage?
Yes No
Uninsured /
Underinsured
Motorists?
Yes No
COMMERCIAL VEHICLE #2:
Year of vehicle:
Make & Model:
Type (long haul trailer/tractor, tow-truck, bobtail, etc.):
Length in Feet:
Radius of operation:
Value $:
List Special Coverages Needed, or Special Equipment to be covered:
VEHICLE #2 COVERAGES:
Limits of
Liability:
State Required Limits Please
$1 Million
$750,000
$500,000 $300,000
$100,000
$60,000
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
Do you want PIP /
Medical Coverage?
Yes No
Uninsured /
Underinsured
Motorists?
Yes No
List Additional Vehicle Information or Additional Drivers Here:
Send my quotation via:
E-Mail Fax
Regular Mail
Call Me by Phone
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