For non-California drivers licenses, please indicate which state or country. For example: 012 345 678 (New York) or 2563487 (British Columbia).
Additional Drivers
If secondary insured has their own vehicle, select "No" and have them submit a separate form.
Driver 2
If drivers license was issued outside of California, please indicate which state or country in addition to ID number. For example: 012 345 678 (New York) or 2563487 (British Columbia)
If secondary insured has their own vehicle, select "No" and have them submit a separate form.
Driver 3
If drivers license was issued outside of California, please indicate which state or country in addition to ID number. For example: 012 345 678 (New York) or 2563487 (British Columbia)
If secondary insured has their own vehicle, select "No" and have them submit a separate form.
Driver 4
If drivers license was issued outside of California, please indicate which state or country in addition to ID number. For example: 012 345 678 (New York) or 2563487 (British Columbia)
If secondary insured has their own vehicle, select "No" and have them submit a separate form.
Driver 5
If drivers license was issued outside of California, please indicate which state or country in addition to ID number. For example: 012 345 678 (New York) or 2563487 (British Columbia)
Vehicle Information
ie. 1985, 1999, 2011
ie. Mercedes-Benz, Toyota, Volkswagen
ie. S550, Camry XLE, Jetta GLS
Vehicle identification number (VIN) can be found on the driver side dashboard, door jam sticker and/or vehicle registration (17-characters).
As of today, how many total miles has your vehicle been driven? Estimate OK
Over the next 12-months, how many miles do you estimate to drive? An average commuter drives between 10,000-13,000 miles per year.
Vehicle 2
ie. 1985, 1999, 2011
ie. Mercedes-Benz, Toyota, Volkswagen
ie. S550, Camry XLE, Jetta GLS
Vehicle identification number (VIN) can be found on the driver side dashboard, door jam sticker and/or vehicle registration (17-characters).
Over the next 12-months, how many miles do you estimate to drive? An average commuter drives between 10,000-13,000 miles per year.
As of today, how many total miles has your vehicle been driven? Estimate OK
Vehicle 3
ie. 1985, 1999, 2011
ie. Mercedes-Benz, Toyota, Volkswagen
ie. S550, Camry XLE, Jetta GLS
Vehicle identification number (VIN) can be found on the driver side dashboard, door jam sticker and/or vehicle registration (17-characters).
Over the next 12-months, how many miles do you estimate to drive? An average commuter drives between 10,000-13,000 miles per year.
As of today, how many total miles has your vehicle been driven? Estimate OK
Vehicle 4
ie. 1985, 1999, 2011
ie. Mercedes-Benz, Toyota, Volkswagen
ie. S550, Camry XLE, Jetta GLS
Vehicle identification number (VIN) can be found on the driver side dashboard, door jam sticker and/or vehicle registration (17-characters).
Over the next 12-months, how many miles do you estimate to drive? An average commuter drives between 10,000-13,000 miles per year.
As of today, how many total miles has your vehicle been driven? Estimate OK
Vehicle 5
ie. 1985, 1999, 2011
ie. Mercedes-Benz, Toyota, Volkswagen
ie. S550, Camry XLE, Jetta GLS
Vehicle identification number (VIN) can be found on the driver side dashboard, door jam sticker and/or vehicle registration (17-characters).
Over the next 12-months, how many miles do you estimate to drive? An average commuter drives between 10,000-13,000 miles per year.
As of today, how many total miles has your vehicle been driven? Estimate OK
Insurance Coverage for Vehicles
Covers medical costs when insured is found to be negligent or at-fault. Uninsured/under insured bodily injury liability coverage will be automatically added to match limits above.
Covers vehicle and property damage repair/replacement costs when insured is found to be negligent or at-fault.
Medical payments differ from bodily injury coverage. The driver does not need to be found liable or at-fault for damages. Often to referred to as "first dollar coverage."
Amount insured must pay before repairs/replacement costs are covered by insurance company. Typical comprehensive claims include vandalism, theft, falling objects and glass damage.
In the event insured is found to be negligent or at-fault, the selected deductible must be paid before repair/replacement costs for insured's vehicle are covered by the insurance company.
Check all that apply.
Insurance Coverage for Vehicle 2
Covers medical costs when insured is found to be negligent or at-fault. Uninsured/under insured bodily injury liability coverage will be automatically added to match limits above.
Covers vehicle and property damage repair/replacement costs when insured is found to be negligent or at-fault.
Medical payments differ from bodily injury coverage. The driver does not need to be found liable or at-fault for damages. Often to referred to as "first dollar coverage."
Amount insured must pay before repairs/replacement costs are covered by insurance company. Typical comprehensive claims include vandalism, theft, falling objects and glass damage.
Insurance Coverage for Vehicle 3
Covers medical costs when insured is found to be negligent or at-fault. Uninsured/under insured bodily injury liability coverage will be automatically added to match limits above.
Covers vehicle and property damage repair/replacement costs when insured is found to be negligent or at-fault.
Medical payments differ from bodily injury coverage. The driver does not need to be found liable or at-fault for damages. Often to referred to as "first dollar coverage."
Amount insured must pay before repairs/replacement costs are covered by insurance company. Typical comprehensive claims include vandalism, theft, falling objects and glass damage.
Insurance Coverage for Vehicle 4
Covers medical costs when insured is found to be negligent or at-fault. Uninsured/under insured bodily injury liability coverage will be automatically added to match limits above.
Covers vehicle and property damage repair/replacement costs when insured is found to be negligent or at-fault.
Medical payments differ from bodily injury coverage. The driver does not need to be found liable or at-fault for damages. Often to referred to as "first dollar coverage."
Amount insured must pay before repairs/replacement costs are covered by insurance company. Typical comprehensive claims include vandalism, theft, falling objects and glass damage.
Insurance Coverage for Vehicle 5
Covers medical costs when insured is found to be negligent or at-fault. Uninsured/under insured bodily injury liability coverage will be automatically added to match limits above.
Covers vehicle and property damage repair/replacement costs when insured is found to be negligent or at-fault.
Medical payments differ from bodily injury coverage. The driver does not need to be found liable or at-fault for damages. Often to referred to as "first dollar coverage."
Amount insured must pay before repairs/replacement costs are covered by insurance company. Typical comprehensive claims include vandalism, theft, falling objects and glass damage.