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Online Automobile Insurance Quote Form for D.U.I. Drivers One Simple Form - takes only 2-3 Minutes! We know how you may feel about your major citation... we will do everything we can to make you feel comfortable, and to assure that your insurance is as low cost as possible! Your Personal Data
Your Name:
Street Address:
City:
Your "County" is?
State:	MUST be Florida!
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)

How Did You Hear About Us? (* REQUIRED! Click on appropriate response.)

DRIVER INFORMATION #1
Name:		Birthdate:
Sex (M/F):		# Years U.S. Licensing:
Drivers License Number: (Required for Discounts)
In Military or Coast Guard?	Yes No	Pay Grade E4/Lower or E5/Higher?
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:		Daily commute in ONE WAY miles:
Does Driver need a DL123 FILING?	Yes No	If YES to DL123 filing, why needed? (list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
Sex:		# Years U.S. Licensing:
Drivers License Number: (Required for Discounts)
In Military or Coast Guard?	Yes No	Pay Grade E4/Lower or E5/Higher?
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:		Number & Type of MINOR Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an DL123 FILING?	Yes No	Comments or Remarks?

VEHICLE #1 INFORMATION (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle:		Make & Model:
Annual Mileage:		Used in business? (Explain, if yes):
VEHICLE #1 COVERAGES:
Limits of Liability:	$30/60 BI / 25 PD $50/100 BI / 50 PD $100/300 BI / 50 PD $250/500 BI / 100 PD

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists Cov.?	Yes No

VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:		Make & Model:
Annual Mileage:		Used in business? (Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of Liability:	$30/60 BI / 25 PD $50/100 BI / 50 PD $100/300 BI / 50 PD $250/500 BI / 100 PD

Comprehensive & Collision:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Do you want Medical Coverage?	Yes No	Uninsured Motorists Cov.?	Yes No

Comments or Remarks: (List additional drivers, autos, etc. here)

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