Contact Information |
* Todays Date:
(mm/dd/yyyy) |
| * First Name: | * Last Name: |
| * Street Address: | * City: |
| * State: | AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY | * Zip: |
| * County: | * Home Phone:
(999-999-9999) |
* Work Phone:
(999-999-9999) | * Email: |
| * Are you currently (or have you ever been) a Brooke customer? | Yes No | * How did you hear about Brooke? |
| Driver Information |
| Driver #1 |
| * Name: | * Date of Birth:
(mm/dd/yyyy) |
| * Gender: | Male Female | * Marital Status: | Single Married Divorced Separated Widowed |
| * Residence: | Own Rent Live With Parents Other | * Relationship to Driver#1: |
Social Security Number:
(e.g. 555-55-5555) | * Drivers License Number: |
| * At what age did this driver first receive their license?: | * Has this driver been a U.S. or Canadian resident for the past 12 months?: | Yes No |
| * Has this driver completed Behind-the-Wheel in the last 5 years?: | Yes No | * Is this driver a full-time student with GPA of 3.0 or above?: | Yes No |
| * In the past 5 years, has the driver's license been suspended or revoked?: | Yes No | * Does the driver require an SR-22 or Financial Responsibility Statement?: | Yes No |
| * In which state is this driver currently licensed?: | AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY | * What is the driver's highest education level?: | Some or No High School High School Diploma G.E.D. Associates Degree Bachelors Degree Masters Degree Doctorate Other |
| * Past or Present Military Experience?: | No Military Experience Active Commissioned Active Enlisted Discharged Commissioned Discharged Enlisted Reserved Commissioned Reserved Enlisted Retired Other | * What is your occupation?: |
| * How long have you been with your occupation?: | * In the past 5 years have you filed for bankruptcy?: | Yes No |
| * In the past 5 years have you had any repossessions, charge offs, or collections?: | Yes No | * How would you describe your credit rating?: | Poor
Good
Excellent
Unsure |
| Driver #2 |
| Name: | Date of Birth:
(mm/dd/yyyy) |
| Gender: | Male Female | Marital Status: | Single Married Divorced Separated Widowed |
| Residence: | Own Rent Live With Parents Other | Relationship to Driver#1: |
Social Security Number:
(e.g. 555-55-5555) | Drivers License Number: |
| At what age did this driver first receive their license?: | Has this driver been a U.S. or Canadian resident for the past 12 months?: | Yes No |
| Has this driver completed Behind-the-Wheel in the last 5 years?: | Yes No | Is this driver a full-time student with GPA of 3.0 or above?: | Yes No |
| In the past 5 years, has the driver's license been suspended or revoked?: | Yes No | Does the driver require an SR-22 or Financial Responsibility Statement?: | Yes No |
| In which state is this driver currently licensed?: | AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY | What is the driver's highest education level?: | Some or No High School High School Diploma G.E.D. Associates Degree Bachelors Degree Masters Degree Doctorate Other |
| Past or Present Military Experience?: | No Military Experience Active Commissioned Active Enlisted Discharged Commissioned Discharged Enlisted Reserved Commissioned Reserved Enlisted Retired Other | What is your occupation?: |
| How long have you been with your occupation?: | In the past 5 years have you filed for bankruptcy?: | Yes No |
| In the past 5 years have you had any repossessions, charge offs, or collections?: | Yes No | How would you describe your credit rating?: | Poor
Good
Excellent
Unsure |
| Driver #3 |
| Name: | Date of Birth:
(mm/dd/yyyy) |
| Gender: | Male Female | Marital Status: | Single Married Divorced Separated Widowed |
| Residence: | Own Rent Live With Parents Other | Relationship to Driver#1: |
Social Security Number:
(e.g. 555-55-5555) | Drivers License Number: |
| At what age did this driver first receive their license?: | Has this driver been a U.S. or Canadian resident for the past 12 months?: | Yes No |
| Has this driver completed Behind-the-Wheel in the last 5 years?: | Yes No | Is this driver a full-time student with GPA of 3.0 or above?: | Yes No |
| In the past 5 years, has the driver's license been suspended or revoked?: | Yes No | Does the driver require an SR-22 or Financial Responsibility Statement?: | Yes No |
| In which state is this driver currently licensed?: | AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY | What is the driver's highest education level?: | Some or No High School High School Diploma G.E.D. Associates Degree Bachelors Degree Masters Degree Doctorate Other |
| Past or Present Military Experience?: | No Military Experience Active Commissioned Active Enlisted Discharged Commissioned Discharged Enlisted Reserved Commissioned Reserved Enlisted Retired Other | What is your occupation?: |
| How long have you been with your occupation?: | In the past 5 years have you filed for bankruptcy?: | Yes No |
| In the past 5 years have you had any repossessions, charge offs, or collections?: | Yes No | How would you describe your credit rating?: | Poor
Good
Excellent
Unsure |
| Incident Information |
| Driver #1 |
Incident 1: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim | Incident 2: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim |
Incident 3: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim | Incident 4: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim |
| Driver #2 |
Incident 1: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim | Incident 2: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim |
Incident 3: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim | Incident 4: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim |
| Driver #3 |
Incident 1: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim | Incident 2: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim |
Incident 3: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim | Incident 4: Date of Incident:
(mm/yyyy) | DUI Ticket Accident Claim |
| Vehicle Information |
| Vehicle #1 |
| * Year: | * Make: |
| * Model: | * VIN #: |
| * Zip Code where vehicle is garaged most: | * Who is the primary driver of this vehicle?: |
| * Is the vehicle primarily driven for commuting, business, or pleasure?: | Commute Work Commute School Commute Varies Pleasure Business | * If used for commuting or business - average number of days per week used?:
(enter "0" if not applicable) |
* If vehicle is used for commuting - what is the average one-way mileage?:
(enter "0" if not applicable) | *Approximately how many miles is the vehicle driven in a year?:
(average american drivers 12,000 per year) |
| * Current Carrier: | * Current Policy Expiration Date:
(mm/dd/yyyy) |
| Comprehensive and Collision deductible: Select the amount you are willing to pay in the event of a claim. The higher the deductible the lower the cost for the coverage. Finance companies require you carry this coverage if you are either purchasing or leasing a vehicle. | * Comprehensive:
No Deductible 100 200 250 500 1000 No Coverage * Collision:
No Deductible 100 200 250 500 1000 No Coverage | * Towing Labor: | Yes No |
| * Rental Reimbursement: | Yes No | * Is this vehicle leased?: | Yes No |
| Vehicle #2 |
| Year: | Make: |
| Model: | VIN #: |
| Zip Code where vehicle is garaged most: | Who is the primary driver of this vehicle?: |
| Is the vehicle primarily driven for commuting, business, or pleasure?: | Commute Work Commute School Commute Varies Pleasure Business | If used for commuting or business - average number of days per week used?:
(enter "0" if not applicable) |
If vehicle is used for commuting - what is the average one-way mileage?:
(enter "0" if not applicable) | Approximately how many miles is the vehicle driven in a year?:
(average american drivers 12,000 per year) |
| Current Carrier: | Current Policy Expiration Date:
(mm/dd/yyyy) |
| Comprehensive and Collision deductible: Select the amount you are willing to pay in the event of a claim. The higher the deductible the lower the cost for the coverage. Finance companies require you carry this coverage if you are either purchasing or leasing a vehicle. | Comprehensive:
No Deductible 100 200 250 500 1000 No Coverage Collision:
No Deductible 100 200 250 500 1000 No Coverage | Towing Labor: | Yes No |
| Rental Reimbursement: | Yes No | Is this vehicle leased?: | Yes No |
| Vehicle #3 |
| Year: | Make: |
| Model: | VIN #: |
| Zip Code where vehicle is garaged most: | Who is the primary driver of this vehicle?: |
| Is the vehicle primarily driven for commuting, business, or pleasure?: | Commute Work Commute School Commute Varies Pleasure Business | If used for commuting or business - average number of days per week used?:
(enter "0" if not applicable) |
If vehicle is used for commuting - what is the average one-way mileage?:
(enter "0" if not applicable) | Approximately how many miles is the vehicle driven in a year?:
(average american drivers 12,000 per year) |
| Current Carrier: | Current Policy Expiration Date:
(mm/dd/yyyy) |
| Comprehensive and Collision deductible: Select the amount you are willing to pay in the event of a claim. The higher the deductible the lower the cost for the coverage. Finance companies require you carry this coverage if you are either purchasing or leasing a vehicle. | Comprehensive:
No Deductible 100 200 250 500 1000 No Coverage Collision:
No Deductible 100 200 250 500 1000 No Coverage | Towing Labor: | Yes No |
| Rental Reimbursement: | Yes No | Is this vehicle leased?: | Yes No |
| |
Ron Davis
