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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 FemaleMarital Status: Single Married Divorced Separated Widowed
Residence:Own Rent Live With Parents OtherRelationship 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 NoIs 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 NoDoes 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 WYWhat 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 OtherWhat 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 NoHow would you describe your credit rating?: Poor
Good
Excellent
Unsure
Driver #3
Name:Date of Birth:
(mm/dd/yyyy)
Gender:Male FemaleMarital Status: Single Married Divorced Separated Widowed
Residence:Own Rent Live With Parents OtherRelationship 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 NoIs 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 NoDoes 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 WYWhat 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 OtherWhat 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 NoHow 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 BusinessIf 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 BusinessIf 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 NoIs this vehicle leased?: Yes No
 

 
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