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Vehicle Information:
Vehicle Year
--Year--
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Make
--Make--
Model
--Model--
Submodel
--Submodel--
Ownership
Leased
Owned
Financed
Primary use
Commute
Pleasure
Business
Farm
Annual mileage
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
11,000
12,000
13,000
14,000
15,000
16,000
17,000
18,000
19,000
20,000
21,000
22,000
23,000
24,000
25,000
26,000
27,000
28,000
29,000
30,000
31,000
32,000
33,000
34,000
35,000
36,000
37,000
38,000
39,000
40,000
41,000
42,000
43,000
44,000
45,000
46,000
47,000
48,000
49,000
50,000
Night parking garage
No Cover
Carport
Locked
Private
Security system
No Alarm
Audible Alarm
Disabling Device
Audible + Disabling
Anti-lock brakers
None
2 Wheels
4 Wheels
Airbags
None
Driver's side only
Dual front airbags
Dual front + side impact
Dual front + side + head
Coverage Information:
Coverage Desired
State Minimum Coverage
Lower Level of Protection
Typical Level of Protection
Highest Level of Protection
Do you require an SR-22 or Financial Responsibility Statement?
Yes
No
Have you filed for bankruptcy in the past 5 years?
Yes
No
Have you had insurance in the past 30 days?
Yes
No
Current insurance company?
Company Not Listed
AAA Insurance Co.
Allstate Insurance
Citizens
Farm Bureau/Farm Family/Rural
Farmers Insurance
Geico General Insurance
Liberty Mutual Insurance
Progressive
State Farm Insurance Co.
Travelers Insurance Company
AAA Insurance Co.
AETNA
AIG
AIU Insurance
Allied
Allstate County Mutual
Allstate Indemnity
Allstate Insurance
American Alliance Insurance
American Automobile Insurance
American Casualty
American Deposit Insurance
American Direct Business Insurance
American Empire Insurance
American Family Insurance
American Family Mutual
American Financial
American Home Assurance
American Insurance
American International Ins
American International Pacific
American International South
American Manufacturers
American Mayflower Insurance
American Motorists Insurance
American National Insurance
American Premier Insurance
American Protection Insurance
American Service Insurance
American Skyline Insurance Company
American Spirit Insurance
American Standard Insurance - OH
American Standard Insurance - WI
Amica Insurance
Arbella
Associated Indemnity
Atlanta Casualty
Atlantic Indemnity
Auto Club Insurance Company
Blue Cross and Blue Shield
Cal Farm Insurance
California State Automobile
Chubb
Citizens
Clarendon American Insurance
Clarendon National Insurance
CNA
Colonial Insurance
Company Not Listed
Continental Casualty
Continental Divide Insurance
Continental Insurance
Cotton States Insurance
Country Insurance Services
Dairyland County Co of TX
Dairyland Insurance
Electric Insurance
Erie Insurance Company
Erie Insurance Exchange
Erie Insurance Group
Erie Insurance and Casualty
Farm Bureau/Farm Family/Rural
Farmers Insurance
Farmers Insurance Exchange
Farmers TX County Mutual
Fire and Casualty Co of CT
Fireman's Fund
Geico Casualty
Geico General Insurance
Geico Indemnity
GMAC Insurance
Golden Rule Insurance
Government Employees Insurance
Grange
Guaranty National Insurance
Hanover Lloyd's Company
Hartford Accident
Hartford Casualty Insurance
Hartford Fire Insurance
Hartford Co of Illinois
Hartford of the Southeast
Hartford Omni
Hartford Underwriters Insurance
Health Plus of America
IFA Auto Insurance
IGF Insurance
Infinity Insurance
Infinity National Insurance
Infinity Select Insurance
Integon
Kaiser Permanente
Kemper Lloyds Insurance
Landmark American Insurance
Leader National Insurance
Leader Preferred Insurance
Leader Specialty Insurance
Liberty Insurance Corp
Liberty Mutual Fire
Liberty Mutual Insurance
Liberty Northwest Insurance
Lumbermens Mutual
Mass Mutual
Mercury
Metropolitan Insurance Co.
Mid Century Insurance
Mid-Continent Casualty
Middlesex Insurance
Midwest National Life
MSI Insurance
Mutual of New York
Mutual Of Omaha
National Ben Franklin Ins
National Casualty
National Continental Ins
National Fire of Hartford
National Health Insurance
National Indemnity
National Union Fire of LA
National Union Fire of PA
Nationwide General Insurance
Nationwide Mutual Fire
Nationwide Mutual Ins
Nationwide Property
New York Life Insurance
Northwestern Mutual Life
Northwestern Pacific
Omni Indemnity
Omni Insurance
Orion Insurance
Pacific Indemnity
Pacific Insurance
Pafco General Insurance
Patriot General Insurance
Peak Property and Casualty
PEMCO Insurance
Progressive
Progressive Auto Pro
Prudential Insurance Co.
Reliance Insurance
Reliance National Indemnity
Reliance National Insurance
Republic Indemnity
Response Insurance
SAFECO
Safeway Insurance
Safeway Co of AL
Safeway Co of GA
Safeway Co of LA
Security Ins of Hartford
Security National of FL
Sentinel Insurance
Sentry Insurance a Mutual
Sentry Insurance Group
Shelter Insurance Co.
St. Paul
St. Paul Fire and Marine
St. Paul Insurance
Standard Fire Insurance
State and County Mutual
State Farm County
State Farm Fire and Cas
State Farm General
State Farm Indemnity
State Farm Insurance Co.
State Farm Lloyds Tx
State Farm Mutual Auto
State National Insurance
Superior American Insurance
Superior Guaranty Insurance
Superior Insurance
The Ahbe Group
TICO Insurance
TIG Countrywide Insurance
Travelers Indemnity
Travelers Insurance Company
Tri-State Consumer Insurance
Twin City Fire Insurance
UniCare
United Pacific Insurance
United Security
United Services Automobile
Unitrin Direct
USAA Casualty Insurance
USAA General Indemnity
USF and G
Viking County Mutual
Viking Insurance Co of WI
Windsor Insurance
Woodlands Financial Group
Company Not Listed
How long insured?
- Select -
Less than 1 year
1-2 years
2-3 years
3-4 years
4-5 years
5+ years
Current policy expires?
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2009
2010
2011
Driver Information
Date of birth
Mo.
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
Marital status
-Select-
Single
Married
Separated
Divorced
Widowed
Gender
Male
Female
Occupation
--Select--
Administrative Clerical
Architect
Business Owner
Certified Public Accountant
Clergy
Construction Trades
Dentist
Disabled
Engineer
Homemaker
Lawyer
Manager Supervisor
Military Officer
Military Enlisted
Minor Not Applicable
Other Non Technical
Other Technical
Physician
Professional Salaried
Professor
Retail
Retired
Sales Inside
Sales Outside
School Teacher
Scientist
Self Employed
Skilled Semi Skilled
Student
Unemployed
Highest education level
- Select -
Some/No High School
High School Diploma
GED
Some College
Associate Degree
Bachelors Degree
Masters Degree
Doctorate Degree
Other Professional Degree
Other Non-Prof. Degree
Trade/Vocational School
Self credit evaluation
Poor
Average
Good
Excellent
Current residence
- Select -
Own
Rent
Other
Years lived there
- Select -
Less than 1 year
1-2 years
2-3 years
3-4 years
4-5 years
5 years or more
License status
Active
Suspended
Probation
Probation/Negligence
Restricted
Learner
Temporary
International
Years licensed (in US)
- Select -
Less than 1 year
1-2 years
2-3 years
3-4 years
4-5 years
5-10 years
10-15 years
15 years or more
Violation (if any)
None
----- MINOR VIOLATIONS -----
Child Seat
Failure to Stop
Illegal U-turn
Seat Belt
Speeding Over 65
Other Minor
Other Yield
----- MAJOR VIOLATIONS -----
Suspension
Driving While Suspended
Drunk Driving - Injury
Drunk Driving - no Injury
Hit and Run - Injury
Hit and Run - no Injury
Reckless Driving - injury
Reckless Driving - no Injury
Speed Contest/Exhibition
Speeding Over 100
----- ACCIDENTS -----
Chargeable Accident - no Injury
Chargeable Accident - Injury
Non-Chargeable Accident
Mo.
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
First name
Last name
Telephone
Email
Zip code
Street address
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