Auto Application - Ledbetter Insurance

Applicant*

First Last

Home Phone*

Work Phone

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Garaging Address*

Click if same as billing address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation/Employer Name*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Occupations

Use checkbox to add more employers

Occupation/Employer	Address

If "Yes" to the following questions, in box below give details.

1. Any existing damage to your vehicle(s)?*

Yes
No

2. Does applicant or any driver have a mental or physical impairment? If Yes, SUBMIT PHYSICIAN'S STATEMENT*

Yes
No

3. Is vehicle used for any type of delivery or used at various job sites during the day?*

Yes
No

4. Do you and all regular drivers listed below live away from above residence more then 2 months a year?*

Yes
No

Explanation of Questions 1 through 4*

Additional Resident Information

Applicant warrants there are no other residents of insured's household(aged 15 and older) and no regular drivers other than those listed below. If additional room is needed, please use the back of the application.

Use checkbox to add more drivers

Name	Sex	Date of Birth	Married	License Number	State	Relation

SR22 Required for Drivers?*

Yes
No

List Driver Name and State for Requiring SR22*

Use checkbox to add more drivers

Driver Name	State

Vehicle Information*

Click checkbox to add additional vehicles.

Year	Make/Model/Style	VIN #	Name & Address of Additional Lienholder or Additional Interest

For each driver list and Describe All Accidents, Moving Violations and Suspensions in past 3 Years below*

Enter 'none' if no accidents, moving violations or suspensions.

VEHICLE(S) MUST BE REGISTERED TO APPLICANT

Business Use?

Use checkbox for any vehicle used for business use.

Vehicle #1
Vehicle #2
Vehicle #3

REJECTION OF UNINSURED/UNDERINSURED MOTORIST COVERAGE

I have applied for bodily injury coverage in limits higher than basic statutory limits. I understand that I may purchase uninsured/underinsured motorist coverage up to the bodily injury limit. I REJECT ADDITIONAL UNINSURED/UNDERINSURED MOTORIST COVERAGE.*

Yes
No

The applicant acknowledges, having been advised of uninsured motorist property damage coverage, the premium therefor, and a brief description of the coverage.*

Yes
No

I certify that all persons age 15 or over who live with me or operate my vehicle(s) have been reported to the Company, and I will inform the Company of future additions.*

Yes
No

NOTICE AS REQUIRED UNDER THE FAIR CREDIT REPORTING ACT(S)
This is to inform you that as part of our procedure for processing your insurance application an investigative consumer report may be requested for the preparation of a report whereby information is obtained through personal interviews with your neighbors, friends or others with whom you are acquainted or who may have knowledge of any such items of information. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living. You have the right to make a written request to be informed as to whether or not such consumer report was requested, and if such report was requested, the name and address of the consumer reporting agency to whom the request was made. You may receive a copy of this report by contacting such agency.

APPLICANT STATEMENT*

Yes
No

The applicant hereto, states that he/she has read this application and warrants that the information provided by the applicant is true and complete and without omission and that said information was provided as an inducement to the insurance company to issue a policy, and it is a special condition of this policy that it shall be NULL and VOID and of no benefit or effect whatsoever as to any claim arising there under in the event that the information in the application should provide to be false or fraudulent in nature. It is understood that NO COVERAGE will be effective if the check given as down payment is not honored by the bank upon which it is drawn.

Name

This field is for validation purposes and should be left unchanged.