Bridenstine & Associates Home Page

	How long have you held a US or Canadian license:	Years Months
	What year did you receive your drivers license:	(YYYY)
	How many years licensed outside the US or Canada:
	Briefly describe your occupation:

	How long has this driver held a US or Canadian license:	Years Months
	What year did this driver receive their license:	(YYYY)
	How many years licensed outside the US or Canada:
	Briefly describe this drivers occupation:

	How long has this driver held a US or Canadian license:	Years Months
	What year did this driver receive their license:	(YYYY)
	How many years licensed outside the US or Canada:
	Briefly describe this drivers occupation:

	How long has this driver held a US or Canadian license:	Years Months
	What year did this driver receive their license:	(YYYY)
	How many years licensed outside the US or Canada:
	Briefly describe this drivers occupation:

Ticket/Violation Information - None, proceed to Vehicle Information.
Enter information on 4 most recent violations in the past 3 years.

	Date (MM/YY)	Driver First and Last Name	Description: (Speeding, Failure to Yield, Failure to Stop, etc...)
1:
2:
3:
4:

Motorcycle Information - Please provide as much information as possible.

Motorcylce 2

Motorcycle 3

Motorcycle 4

Accident/Collision Losses -

Enter information on the 3 most recent losses in the past 3 years.
1: Approximate Date - Month and Year (mm/yy):
First name of driver in your household involved, if any:
Amount of claim for Property Damage paid by your insurance, if any:
Amount of claim for Bodily Injury paid by your insurance, if any:
Driver in your household considered to be at-fault or ticketed for accident:	Yes No

Briefly describe accident, injuries, and damages:

2: Approximate Date - Month and Year (mm/yy):
First name of driver in your household involved, if any:
Amount of claim for Property Damage paid by your insurance, if any:
Amount of claim for Bodily Injury paid by your insurance, if any:
Driver in your household considered to be at-fault or ticketed for accident:	Yes No

Briefly describe accident, injuries, and damages:

3: Approximate Date - Month and Year (mm/yy):
First name of driver in your household involved, if any:
Amount of claim for Property Damage paid by your insurance, if any:
Amount of claim for Bodily Injury paid by your insurance, if any:
Driver in your household considered to be at-fault or ticketed for accident:	Yes No

Briefly describe accident, injuries, and damages:

Claims/Comprehensive Losses
Enter information on the 3 most recent losses in the past 3 years.

	Date (MM/YY)	Amount Paid	Description: (Windshield Replaced, Vehicle Theft, Stereo Theft, Fire damage, Key Scratch, etc...)
1:
2:
3:

Insurance Carrier Information

Currently insured: Not insured, proceed to Other Information

If insured, select insurance carrier:
Expiration date: (MM/DD/YYYY)
Approximately how long insured with this company:	Years Months
How long you have been continuously insured. Not necessarily with your present carrier:	Year Months

Other Information

	What is your current annual insurance premium:	$
	What amount of annual savings would you consider changing insurance companies for:
	Most insurance companies provide a substantial discount if you insure your vehicles and residence with them. Would you be interested in this discount?
	Do you have health insurance? Some states require extra medical coverage under your auto insurance if you do not.