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1
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Accidents Within 5 Years?
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No
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No
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License Number
Accidents Within 5 Years?
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No
At Fault With Injury
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Not At Fault
Violations Within 5 Years?
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No
Careless Driving
Defective Equipment
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DUI
Failure to Obey Signal
Speeding 1-5
Speeding 6-10
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Completed any safety courses?
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Yes
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Operator 4 Name
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License Number
Accidents Within 5 Years?
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No
At Fault With Injury
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Violations Within 5 Years?
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No
Careless Driving
Defective Equipment
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Failure to Obey Signal
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Speeding 6-10
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Completed any safety courses?
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Yes
No
Don't Know
Operator 5 Name
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Michigan
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Mississippi
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Ohio
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Rhode Island
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Texas
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Child
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Other
License Number
Accidents Within 5 Years?
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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
Completed any safety courses?
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Yes
No
Don't Know
Trailer and Storage
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Armed Forces Americas
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Storage Zip
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