Mancini Insurance
Agency
11269 Perry Hwy. #300
Wexford, PA 15090
Phone: 724-933-8637
Fax: 724-933-8600
DRIVER INFORMATION #1
Name:
Birthdate:
Sex (M/F):
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute in ONE WAY miles:
Does Driver need a DL123 FILING?
Yes
No
If YES to DL123 filing, why needed? (list accident/cite)
DRIVER INFORMATION #2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years:
Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an DL123 FILING?
Yes
No
Comments or Remarks?
VEHICLE #1 INFORMATION
Year of vehicle:
Make & Model:
Value of vehicle:
Additions or Alterations:
Annual Mileage:
How Often is Vehicle Used & for What Purposes?
Where is Vehicle Kept, Describe locked garage?:
Vehicle Originally equipped? (describe modifications)
VEHICLE #1 COVERAGES:
Select Liability Limits
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists Cov.?
Yes
No
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle:
Make & Model:
Value of vehicle:
Additions or Alterations:
Annual Mileage:
How Often is Vehicle Used & for What Purposes?
Where is Vehicle Kept, Describe locked garage?:
Vehicle Originally equipped? (describe modifications)
VEHICLE #2 COVERAGES:
Limits of Liability:
(Must be the Same as Vehicle #1)
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists Cov.?
Yes
No
Comments or Remarks:
(List additional drivers, autos, etc. here)
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