Date:
(ex: 04/17/2003)
Name:
Visa Status :
F1
H1
R1
Resident
Citizen
Company Name:
Occupation:
Home Telephone #:
(ex:718-222-0000)
Work Telephone #:
(ex:
718-222-0000
)
E-Mail Address #1:
E-Mail Address #2:
Single
Married
Student Member
Inbound Member
DRIVER #1:
License#:
Date of Birth:
(ex: 04/17/2003)
Age 1st Lisenced:
(ex: 04/17/2003)
Address:
Accident/Violation:
DRIVER #2:
License#:
Date of Birth:
(ex: 04/17/2003)
Age 1st Lisenced:
(ex: 04/17/2003)
Address:
Accident/Violation:
Year:
Vin#:
Make:
# of Doors:
Model:
# of Airbags:
# of Cylinders:
Manual:
Yes
No
Not Sure
Anti-lock Breakes:
Yes
No
Not Sure
Automatic Alarm:
Yes
No
Not Sure
Auto Seat Belts:
Yes
No
Not Sure
Is car used for pleasure?
Yes
No
Not Sure
Miles driven 1-way to work?
miles
Days per week car is used for commuting?
days
Company Car Information?
(ex:
Year/Make/Model)
Mileage per year?
miles
--
Standard Coverage --
Bodily Injury:
(
$100/300,000 person/accident)
Property Damage:
(
$50,000 each accident)
Personal Injury Protection:
(
Med Exp. W/250 ded, Basic)
Uninsured Motorist:
(
$100/300,000 person/accident)
Other Than Collision:
(
$100/250/500)
Collision:
(
$100/250/500)
Towing & Labor:
(
$75 per disablement-
optional
)
Extended Transportation:
(
30/day max $900-
optional
)
* Use "S" to indicate standard coverage listed at right
¨Ï 2006 JJC Agency Corporation. All rights reserved.
