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     42 Year old male in Snellville, GA. 2009 Honda Accord, $25/50/25 Minimum Liability Limits with uninsured motorists, $500 ded. comp & collision with SR22.
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    SR22 Georgia Insurance.com
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    Phone: 678-407-9277
    Fax: 888-309-3880 E-Mail us at: firstoptioninsurance@yahoo.com Mailing Address: PO Box 851
    223 Scenic Hwy., Suite 104
    Lawrenceville, GA 30046

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    continuous. If none, type N/C)

    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
    an SR22 FILING?    		 Yes No If YES to SR22 filing, why needed?
    (list accident/cite)
    Give details on all violations or accidents:

    DRIVER INFORMATION #2 (if none, leave blank)
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    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:
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    in ONE WAY miles:
    Does Driver need
    an SR22 FILING?    		 Yes No Comments or
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    If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

    VEHICLE #1 INFORMATION
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    Year of vehicle: Make & Model:
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    VEHICLE #2 INFORMATION (if none, leave blank)
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    Vehicle ID# (for rating accuracy):
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    Match Vehicle #1 - - -
     
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    Comments or Remarks:
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