Capps Insurance.com

Car #1

Year

Make

Model

2dr/4dr

Miles to Work (one way)

Annual Mileage

Driver #1 Information
Driver Name
Date of Birth
Drivers License Number
Occupation
Employer
Number of Years w/ Current Employer
Social Security Number
	Sex:	Male	Female
Marital Status
Moving Violations in Last 3 Years		0 1 2 3
Explain
Accidents in Last 3 Years		0 1 2 3
Explain

Driver #2 Information
Driver Name
Date of Birth
Drivers License Number
Occupation
Employer
Number of Years w/ Current Employer
Social Security Number
	Sex	Male	Female
Marital Status
Moving Violations in Last 3 Years		0 1 2 3
Explain
Accidents in Last 3 Years		0 1 2 3
Explain

Driver #3 Information
Driver Name
Date of Birth
Drivers License Number
Occupation
Employer
Number of Years w/ Current Employer
Social Security Number
Sex	Male	Female
Marital Status
Moving Violations in Last 3 Years	0 1 2 3
Explain
Accidents in Last 3 Years	0 1 2 3
Explain

Liability Limit for All Cars
Choose either Bodily Injury & Property Damage OR Single Limit
Bodily Injury	Property Damage	Single Limit choose one
20,000/40,000	15,000	40,000
25,000/50,000	25,000	60,000
50,000/100,000	50,000	100,000
100,000/300,000	100,000	300,000
250,000/500,000	500,000	500,000

Car #3
Deductible Comprehensive	100	250	500
Deductible Collision	250	500	1000
Tow	Yes
Loss of Use / Rental	Yes

Death Indenmity/Disability	Yes	No
Comments
* Credit Report, CLUE Report, and MVR may be used for underwriting and pricing purposes.

Capps Insurance - Mt. Pleasant
1610 Shadywood Lane
Mt. Pleasant, TX 75455
(903)572-4366
(800)256-1905

Capps Insurance - Clarksville
312 W. Broadway
Clarksville, TX 75426
(903)427-5656
(800)941-3444