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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
 

 
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Fred Griffin
Frederick Griffin, Licensed Real Estate Broker - Tallahassee, FL
Licensed Florida Real Estate Broker

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May 07, 2016 09:59 PM #1
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