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5
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Last
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Address Line 2
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Armed Forces Americas
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Phone
(Required)
Alternate Phone
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Marital Status
(Required)
Single
Married
Divorced
Separated
Widowed
Gender
(Required)
Male
Female
Own or Rent Home
Own
Rent
Currently Insured
Yes
No
If no, when did you last have insurance?
MM slash DD slash YYYY
Current Carrier
How did you hear about us?
None
Current Customer
Friend
Coverage Options
Bodily Injury Liability
(Required)
$10,000/$20,000
$20,000/$40,000
$25,000/$50,000
$30,000/$60,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
Property Damage Liability
(Required)
$10,000
$15,000
$25,000
$50,000
$100,000
$250,000
$300,000
Uninsured Motorist Bodily Injury
$10,000/$20,000
$20,000/$40,000
$25,000/$50,000
$30,000/$60,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
Uninsured Motorist Property Damage
$10,000
$15,000
$25,000
$50,000
$100,000
$250,000
Underinsured Motorist Bodily Injury
$10,000
$15,000
$50,000
$100,000
$250,000
Medical Pay / PIP
None
$1,000
$5,000
$10,000
$15,000
$25,000
Vehicle Information
Vehicles
Vehicle (Year/Make/Model)
(Required)
VIN Number
Annual Mileage
Drive to Work or School
Yes
No
Number of Miles (One Way)
Days Per Week
Comprehensive Deductible
50
100
250
500
1000
Collision Deductible
50
100
250
500
1000
Towing
20
30
35
40
50
75
Rental
20
25
30
35
40
45
50
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Driver Information
Drivers
Name
(Required)
First
Last
Vehicle Used
(Required)
Relationship
(Required)
Self
Spouse
Child
Parent
Gender
(Required)
Male
Female
Marital Status
(Required)
Single
Married
Divorced
Separated
Widowed
Date of Birth
(Required)
MM slash DD slash YYYY
Percent Use
Driver License Number
State Issued
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
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MD
ME
MI
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MO
MS
MT
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OK
OR
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VT
WA
WI
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WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
INT
SR22 Required
Yes
No
Add Driver
Remove Driver
Violations
Drivers
Violation Type
None
Accident At-Fault
Accident Not At-Fault
Accident with Pedestrian
Aggravated Assault with an Auto
All Other Moving Violations
All Other Non-Moving Violations
Allow Unlicensed Driver to Drive
Altered or Forged VIN
Avoiding Traffic-Control Device
Bus/Car Pool/ Hov - Lane Violation
Careless and Imprudent Driving
Changing Driver in Moving Vehicle
Changing Lanes when Unsafe
Crossing Center Median
Crossing Divided Highway
Crossing Yellow Line
Disobey Police Order
Display Altered/Counterfeit DL
Display Another Person's DL
Disregard No Passing Zone
Drive Left of Center
Driving at Night Without Lights
Driving on Left Side of Roadway
Driving on Shoulder
Driving on Sidewalk or Parkway
Driving on Wrong Side of Road
Driving Too Fast for Conditions
Driving Too Slow for Conditions
Driving While Suspended or Revoked
Driving With an Expired License
Driving Without a License or Permit
Driving Wrong Way on One-Way
Drv Under Minimum Speed Limit
DUI Drugs/Opiates
Duplicate Drivers License
Eluding Police/Evading Arrest
Excessive Acceleration
Failure to Control Speed
Failure to Dim Headlights
Failure to Display DL
Failure to Give Stop or Turn Signal
Failure to Keep Right
Failure to Stop for Approaching Train
Failure to Stop for Railroad Crossing
Failure to Stop for Red Light
Failure to Stop for Stop Sign
Failure to Yield (Pedestrian)
Failure to Yield Right of Way
Failure to Yield to Emergency Vehicle
False License or Registration
Giving Improper Signal
Homicide with a Motor Vehicle
Illegal Pass on Right
Improper Merging Into Traffic
Improper Passing
Improper Passing of a School Bus
Improper Start
Improper Towing or Pushing of Vehicle
Improper Use of Lane
Improperly Backing
Light Violations (Head, Tail, etc..)
Loaned DL to Another Person
Motorcycle Equipment Violation
No Chauffeurs License
No Drivers License
No Motorcycle Qualification
Obtaining License by Misrepresenting
Operating During Life Suspension
Operating Out of Class
Operating Where Prohibited
Operating with Defective Equipment
Overheight Vehicle
Overlength Vehicle
OWI
Possession of Controlled Substance
Racing/Speed Contest
Speeding
Speeding in a School Zone
Squealing or Screeching Tires
Suspension (Chargeable)
Turned Across Divided Section
Turned When Unsafe
Unsafe Speed
Unsafe Start, Park, Stop, Standing
Vehicular Manslaughter
Violation of DL Restriction
Violation of Instruction Permit
Violation of Liquor Law
Wrong Direction Around Traffic Island
Wrong Direction Divided Street
Allow Unlawful Operation of Vehicle
Coasting with Gears Disengaged
Comprehensive Claim
Consuming Alcohol While Driving
Conviction of Insurance Fraud
Criminal Negligence
Disregard of Safety
Drivers View Obstructed
Driving Over Fire Hose
Driving School Bus While Intoxicated
Driving Through Safety Zone
Driving W/O Owners Consent
DUI Alcohol/Liquor
DWAI
DWI
Educational Program Required (ARD)
Failure of Duty
Failure to Control Vehicle
Failure to Exchange Info After Accident
Failure to Pay Toll
Failure to Sound Horn
Failure to Wear Seat Belt
Felony Involving a Motor Vehicle
Following Improperly
Following Too Close
Illegal Transportation of Alcohol
Impeding Traffic Movement
Implied Consent/Refuse Breath Test
Improper Driving
Improper Entering/Leaving Turnpike
Increase Speed While Being Passed
Leave Vehicle With Engine Running
Leaving Scene / Hit-and-Run
Medical Payments Claim
Motor Vehicle Inspection Viol.
Negligent Collision
Negligent Driving
No Liability Insurance in Force
Open Container Violation
Parking on Roadway
Prohibited U Turn
Protective Head Gear Violation
Reckless Driving
Stealing Auto
Underinsured Motorist Claim
Uninsured Motorist Claim
Unrestrained Child
Unsafe Operator
Vehicle Emissions Suspension
Vehicular Injury
Violating Safety Zone
Violation of Promise to Appear
Driver
Date Occurred
MM slash DD slash YYYY
Additional Information
Bodily Injury/Property Damage/Both
Add Violation
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