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Credit Report Consent
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Anti Theft Features
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None
Automatic Seatbelts
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Anti-Lock Brakes
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Daytime Running Lights
Yes
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Any Prior Damage to Vehicle?
Yes
No
Vehicle Ever Used for Deliveries?
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No Coverage
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50
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No Coverage
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50
100
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Towing/Roadside Coverage
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No
25
50
75
100
250
Rental Reimbursement
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No
15
20
30
40
50
Full Glass Coverage?
Yes
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Third Choice
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MM slash DD slash YYYY
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We only insurance Kentucky and Tennessee
License Number
Suspended in Last 5 Years
No
Yes
Third Choice
Occupation
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Accountant
Administrator/Director
Adjusters
Administrative
Agronomist
Airline Personnel
All other officers and employees not...
Appraiser
Architect
Artist (Without Other Profession)
Athlete - Professional
Actuary
Auditor
Automobile Mechanic
Automobile Sales/Dealer
Bank/Financial Institution -...
Bank/Financial Institution - Clerical
Bookkeeper
Bank/Financial Institution - Management
Barber, Hairdresser
Buyer
Chartered Accountant
Canvasser (Door-to-Door Salesperson)
Cashier
Crown Corporation Employee
Credit Clerk
Craftsman
Chef
Chiropractor
Consultant - Human Resources
Chairperson
Clergy
Computer - Analyst, Consultant,...
Comptroller
Collector
Consultant - Other (Use 5RMK -...
Certified Public Accountant
Carpenter
Courts e.g. Bailiff, Clerk, Reporter,...
Civil Service
Custodian
Consultant - Training
Daycare Worker, Provider
Delivery
Dentist
Dental Hygenist
Dietician, Nutritionist
Dieticians who order food
Disabled/Unable to work
Demonstrator
Driver
Driver - Local Delivery
Driver - Long Haul, Mover
Driver - Public Transportation
Driver - Taxi, Chauffeur, Instructor
Electrician
Engineer
Entertainment Field e.g. Actor,...
Executive
Factory Worker, Machine Operator,...
Firefighter
Financial Advisor, Broker, Economist
Fitness, Health Employee
Flagged Occupation
Flight Attendant
Food Industry - Other e.g. Butcher,...
Food Inspector
Forest Employee
Farmer
Fisherman
General Contractor
Graphic Designer, Printer
C
Hotel, Motel Worker
Horticulture
Insurance - Agent, Broker
Insurance - Adjuster
Instructor
Insurance - Underwriter
Janitors
Labourer - Unskilled
Lawyer
Librarian
Locker room attendants
Maitre D's and assistants
Medical Director
Manager
Military (Armed Forces)
Miner
Marketing Employee
Maintenance, Janitor, Cleaner
Messenger
Medical Specialist e.g. Anaesthetist,...
Nurse
Notary
Office, Sales
Optician
Optometrist, Opthamologist
Other
Professional, Advanced degree
Payroll Distributor
Professional, College degree
Photographer, Photography Studio
Pharmacist
Physician
Pilot
Painter, Plasterer
Professional Manager
Police Officer
Professor
Postal Worker
Public Transportation Worker - Other...
Purchasing Agent
Real Estate Agent
Receiving Clerk
Retired
Refinery Gauger of Oil Company
Restaurant, Bar - Owner, Employee...
Restaurant, Bar - Chef, Cook, Caterer
Retail Sales Person
Salaried
Salesperson - Commercial
Scientist
School Teacher
Self-Employed
Security Officer, Worker
Shipping Clerk
Skilled, Semi-Skilled
Seamstress
Supervisor, Foreman
Spouse at Home
Service Station attendants
Student
Storekeeper
Stock Clerk
Storeroom Personnel
Superintendent
Technicians - Research, Medical
Technical /Supervisory
Therapist
Timekeeper
Teachers having custody of money or...
Tradesman
Truck Driver
Unknown
Unemployed
Unskilled
Veterinarian
Warehouse Personnel
Wine Cellar Personnel
Wine Steward/ess
Writer, Publisher
Education
Select...
Some High School
High School Graduate
GED
Vocational/Technical
Some College
Associate Degree
Bachelors Degree
Masters Degree
Doctorate
Medical School
Law School
Primary Vehicle
Not Provided
Age Licensed
Accidents Within 5 Years?
Select...
No
At Fault With Injury
At Fault With No Injury
Not At Fault
Violations Within 5 Years?
Select...
No
Careless Driving
Defective Equipment
Driving on Sus. License
DUI
Failure to Obey Signal
Speeding 1-5
Speeding 6-10
Speeding 11-15
Speeding 16-20
Speeding 21+
Speeding Violation-Major
Speeding Violation-Minor
Other Major
Other Minor
Ticket Violation Not Listed
SR22 Filing?
Select...
Yes
No
Don't Know
Eligible For Good Student Discount?
Select...
College Graduate
Good Student Credit May Apply
No
Don't Know
Eligible For Defensive Driver Discount?
Yes
No
Don't Know
Eligible For Drivers Ed Discount?
Yes
No
Don't Know
Bodily Injury
$15,000/$30,000
$25,000/$50,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
Property Damage
$5,000
$10,000
$25,000
$50,000
$100,000
Uninsured Motorist
Select...
None/Reject
$15,000/$30,000
$20,000/$40,000
$25,000/$50,000
$30,000/$60,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
$300,000/$300,000
$500,000/$500,000
$1,000,000/$1,000,000
$55,000 CSL
$100,000 CSL
$300,000 CSL
$500,000 CSL
$1,000,000 CSL
Underinsured Motorist
Select...
None/Reject
$15,000/$30,000
$20,000/$40,000
$25,000/$50,000
$30,000/$60,000
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
$300,000/$300,000
$500,000/$500,000
$1,000,000/$1,000,000
$55,000 CSL
$100,000 CSL
$300,000 CSL
$500,000 CSL
$1,000,000 CSL
Medical Payment
Select...
Reject
$1,000
$10,000
$15,000
$20,000
$25,000
$50,000
$100,000
$250,000
$500,000
First Pay Benefits (Medical, Funeral, Accidental Death, Income Loss, EMB)
Yes
No
Tort Option
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Full Tort
Limited Tort
Do you Have Auto Insurance Now?
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Yes
No
Previous (or Current) Carrier
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No Prior Insurance
AAA
Acuity
Allied P&C
Allied AMCO
Allmerica
Allstate
American Family
A.I.G.
Atlantic Casualty
Auto-Owners
Buckeye
Cameron
Central Mutual
Chubb
Cincinatti
Columbia
Consumers
C.N.A.
Cornerstone
Continental
Countrywide
Criterion
Dairyland
Deerbrook
Direct
Economy
Employers Mutual
Esurance
Farm Bureau
Farmers
Farmers Alliance
Farmers and Merchants
Farmers Mutual of NE
Fidelity National
Firemans Fund
First National
Foremost
Gallant
Gateway
GEICO
General Casualty
GMAC
Grange Mutual
Granite State
Great American
Grinnell Mutual
Guide One
Hanover
Hartford
Hauler's
Hawkeye
Infinity
Kemper
Leader
LeMars
Liberty Mutual
Madison Mutual
Mercury
Meridian
MetLife
Metropolitan
Nationwide
Progressive
Prudential
St Paul
Safeco
Sagamore
Selective
Sentry
Shelter Mutual
State Auto
State Farm
Traders
Travelers
Trustguard
Twentieth Century
Unitrin
USAA
Viking
Wadena
West Bend Mutual
Windsor
White Mountains
Yellow Key
Other
Current Policy Premium
Current Policy Expiration
MM slash DD slash YYYY
Years With Previous (or Current) Insuror
Years Of Continuous Coverage
Agent Name (Optional)
How Did You Hear About Us?
Select...
Customer Referral
Friend or Family Member
Google
Yahoo!
bing
Other Internet Search
Sales Representative
Flyer/Brochure
Phone Book
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Dave Ramsey ELP Program
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Email
Regular Mail
Door Hanger/Handbill
Other
Preferred Contact Method
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By Phone (Day)
By Phone (Evening)
By Email
Additional Comments
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