Auto Insurance for International students – Get a free quote Step 1 of 5 20% General InformationProgramMG/EP - personal Auto ProgramMG/EN - Non Owner ProgramRisk StateVirginiaEffective Term:6 months12 monthsPrior CoverageTypeNoneAgency Internal TransferPrior Coverage - Full TermPrior Coverage - Midterm CancellationPrior Coverage Expiration Name First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Last Four of SSNLast four of SSN recommended in order to provide the most accurate quotePhoneEmail Home OwnerYesNoTime at Current AddressYears :Months Driver(s) InformationNumber of drivers (Please get in touch with us if more than 2 drivers)12Driver 1RelationNamed InsuredName First Last DOB Marital StatusSingleMarriedDivorcedWidowedSeperatedGenderMaleFemaleLicense StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDriver's License NumberYears LicensedNo US LicenseLess than 11 or less than 22 or less than 33+License StatusCurrentExpiredRevokedSuspendedCancelledSenior Defence DriverYesNoSR-22YesFR-44NoCompletion Date SR-22 CaseNumber of incidents for driver 1012IncidentsDate Incident1-5 OVER LIMITAccidentAccident At FaultAccident Not At FaultAGGRESSIVE DRIVINGCareless/Improper DrivingChild Restraint ViolationComp Loss/ClaimDefective EquipmentDriving in HOV Line/Center MedianDriving too fast or slow for conditionsDriving with suspended licenseDriving without a valid licenseDriving Under the InfluenceExpired tag/registrationFailure to appearFailure to display drivers licenseFailure to obey traffic deviceFailure to signalFailure to surrender license/reg/plateFailure to yieldFailure to yield to emergency vehicleFalse reportFalsification of proof of financial respFelony with a motor vehicleFinancial responsibility - no insuranceHit and run accidentImproper backingImproper passingIMPROPER SIGNALIMPROPER TURNLane change violationMinor moving violation - otherNon-moving violation - otherObstructed viewOpen containerPassing stopped school busPossess/use/sell dangerous substanceRacing / speed contestRefusal to submit to chemical testSeat belt violationSpeedingSuspended license currentlyUnlawful use of vehicleVehicular manslaughter11-15 OVER LIMIT16-20 OVER LIMIT21-25 OVER LIMIT31-35 OVER LIMIT6-10 OVER LIMITDate Incident1-5 OVER LIMITAccidentAccident At FaultAccident Not At FaultAGGRESSIVE DRIVINGCareless/Improper DrivingChild Restraint ViolationComp Loss/ClaimDefective EquipmentDriving in HOV Line/Center MedianDriving too fast or slow for conditionsDriving with suspended licenseDriving without a valid licenseDriving Under the InfluenceExpired tag/registrationFailure to appearFailure to display drivers licenseFailure to obey traffic deviceFailure to signalFailure to surrender license/reg/plateFailure to yieldFailure to yield to emergency vehicleFalse reportFalsification of proof of financial respFelony with a motor vehicleFinancial responsibility - no insuranceHit and run accidentImproper backingImproper passingIMPROPER SIGNALIMPROPER TURNLane change violationMinor moving violation - otherNon-moving violation - otherObstructed viewOpen containerPassing stopped school busPossess/use/sell dangerous substanceRacing / speed contestRefusal to submit to chemical testSeat belt violationSpeedingSuspended license currentlyUnlawful use of vehicleVehicular manslaughter11-15 OVER LIMIT16-20 OVER LIMIT21-25 OVER LIMIT31-35 OVER LIMIT6-10 OVER LIMITDriver 2RelationNamed InsuredName First Last DOB Marital StatusSingleMarriedDivorcedWidowedSeperatedGenderMaleFemaleLicense StateVirginiaSecond ChoiceThird ChoiceDriver's License NumberYears LicensedNo US LicenseLess than 11 or less than 22 or less than 33+License StatusCurrentExpiredRevokedSuspendedCancelledSenior Defence DriverYesNoSR-22YesSR-44Third ChoiceCompletion Date SR-22 CaseNumber of incidents for driver 2012IncidentsDate Incident1-5 OVER LIMITAccidentAccident At FaultAccident Not At FaultAGGRESSIVE DRIVINGCareless/Improper DrivingChild Restraint ViolationComp Loss/ClaimDefective EquipmentDriving in HOV Line/Center MedianDriving too fast or slow for conditionsDriving with suspended licenseDriving without a valid licenseDriving Under the InfluenceExpired tag/registrationFailure to appearFailure to display drivers licenseFailure to obey traffic deviceFailure to signalFailure to surrender license/reg/plateFailure to yieldFailure to yield to emergency vehicleFalse reportFalsification of proof of financial respFelony with a motor vehicleFinancial responsibility - no insuranceHit and run accidentImproper backingImproper passingIMPROPER SIGNALIMPROPER TURNLane change violationMinor moving violation - otherNon-moving violation - otherObstructed viewOpen containerPassing stopped school busPossess/use/sell dangerous substanceRacing / speed contestRefusal to submit to chemical testSeat belt violationSpeedingSuspended license currentlyUnlawful use of vehicleVehicular manslaughter11-15 OVER LIMIT16-20 OVER LIMIT21-25 OVER LIMIT31-35 OVER LIMIT6-10 OVER LIMITDate Incident1-5 OVER LIMITAccidentAccident At FaultAccident Not At FaultAGGRESSIVE DRIVINGCareless/Improper DrivingChild Restraint ViolationComp Loss/ClaimDefective EquipmentDriving in HOV Line/Center MedianDriving too fast or slow for conditionsDriving with suspended licenseDriving without a valid licenseDriving Under the InfluenceExpired tag/registrationFailure to appearFailure to display drivers licenseFailure to obey traffic deviceFailure to signalFailure to surrender license/reg/plateFailure to yieldFailure to yield to emergency vehicleFalse reportFalsification of proof of financial respFelony with a motor vehicleFinancial responsibility - no insuranceHit and run accidentImproper backingImproper passingIMPROPER SIGNALIMPROPER TURNLane change violationMinor moving violation - otherNon-moving violation - otherObstructed viewOpen containerPassing stopped school busPossess/use/sell dangerous substanceRacing / speed contestRefusal to submit to chemical testSeat belt violationSpeedingSuspended license currentlyUnlawful use of vehicleVehicular manslaughter11-15 OVER LIMIT16-20 OVER LIMIT21-25 OVER LIMIT31-35 OVER LIMIT6-10 OVER LIMITADDITIONAL DRIVER GUIDELINES List all persons 14 years or older, licensed or not, residing with applicant(s), whether or not they drive/operate the listed vehicle(s). List all regular operators of said vehicle(s). List students living away from home, persons In the Armed Services, and any children or dependents of the applicant or applicant’s spouse between the age of 14 and 21 who do not reside with insured. If the person has never been licensed, or if the license has been permanently surrendered and they do not drive, they may be listed as an Unlicensed Resident; otherwise, they must be listed as a Driver. If the person has held a Virginia license, that license must be entered as the driver’s license information. Failure to list all such persons with complete information may constitute a material misrepresentation, which may result in all insurance coverages being void.Have all people described above been listed on the application?N/AYesNoHas the Virginia license information been entered for all drivers who have held a Virginia license that has not expired or been permanently surrendered?N/AYesNo Unlicensed Residents* For individuals in the household without a license. *Number of unlicensed residents (Please contact us if you have more than 4 unlicensed residents)01234Unlicensed Resident 1 detailsName First Last RelationSpouseChildRelativeNon-RelativeOccupationA/C & HeatingAluminumAppliance Inst.Brick LayerBuilding Cont.Cabinet Inst,Cabinet MakerCable TV Inst,CarpenterCarpet CleanerCarpet Inst.ClergymanConcrete Cont.Covering Cont.Drywall Cont.ElectricalEmployedExterminatorFence Inst.Glass HandlerHandymanHomemakerInt. DecoratorLawn Maint.Mansory Cont.MasonMilitaryPainterPainting Cont.Paper HangerPersonalPest ControlPlasteringPlumberPool CleanerPool ContractorRealtorRetiredSalesScreens and Enc.Self-EmployedSheet Metal MecStudentSurveyorTile ContractorUnemployedOtherDate of Birth GenderMaleFemaleUnlicensed Resident 2 detailsName First Last RelationSpouseChildRelativeNon-RelativeOccupationA/C & HeatingAluminumAppliance Inst.Brick LayerBuilding Cont.Cabinet Inst,Cabinet MakerCable TV Inst,CarpenterCarpet CleanerCarpet Inst.ClergymanConcrete Cont.Covering Cont.Drywall Cont.ElectricalEmployedExterminatorFence Inst.Glass HandlerHandymanHomemakerInt. DecoratorLawn Maint.Mansory Cont.MasonMilitaryPainterPainting Cont.Paper HangerPersonalPest ControlPlasteringPlumberPool CleanerPool ContractorRealtorRetiredSalesScreens and Enc.Self-EmployedSheet Metal MecStudentSurveyorTile ContractorUnemployedOtherDate of Birth GenderMaleFemaleUnlicensed Resident 3 detailsName First Last RelationSpouseChildRelativeNon-RelativeOccupationA/C & HeatingAluminumAppliance Inst.Brick LayerBuilding Cont.Cabinet Inst,Cabinet MakerCable TV Inst,CarpenterCarpet CleanerCarpet Inst.ClergymanConcrete Cont.Covering Cont.Drywall Cont.ElectricalEmployedExterminatorFence Inst.Glass HandlerHandymanHomemakerInt. DecoratorLawn Maint.Mansory Cont.MasonMilitaryPainterPainting Cont.Paper HangerPersonalPest ControlPlasteringPlumberPool CleanerPool ContractorRealtorRetiredSalesScreens and Enc.Self-EmployedSheet Metal MecStudentSurveyorTile ContractorUnemployedOtherDate of Birth GenderMaleFemaleUnlicensed Resident 4 detailsName First Last RelationSpouseChildRelativeNon-RelativeOccupationA/C & HeatingAluminumAppliance Inst.Brick LayerBuilding Cont.Cabinet Inst,Cabinet MakerCable TV Inst,CarpenterCarpet CleanerCarpet Inst.ClergymanConcrete Cont.Covering Cont.Drywall Cont.ElectricalEmployedExterminatorFence Inst.Glass HandlerHandymanHomemakerInt. DecoratorLawn Maint.Mansory Cont.MasonMilitaryPainterPainting Cont.Paper HangerPersonalPest ControlPlasteringPlumberPool CleanerPool ContractorRealtorRetiredSalesScreens and Enc.Self-EmployedSheet Metal MecStudentSurveyorTile ContractorUnemployedOtherDate of Birth GenderMaleFemale VEHICLE(S) INFORMATIONNumber of Vehicles (Please contact us if more than 2 vehicles)12Vehicle 1 detailsZipVINVIN Override YearChoose...201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925ModelMakeStyleGaraging Address same as mailing?YesNoAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Lienholder/Additional Interest Name Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Vehicle History How long has the vehicle been registered in your name?Not registered in my name0-2 months3-6 months7-12 months1 - <2 years2 - <3 years3- <5 years5+ yearsUnknownAre you the first owner of the vehicleUnknownYesNoCompNo Coverage2505007501000UsePleasureTo and from workTo and from schoolArtisanBusiness useCollNo Coverage2505007501000Loss PayeeYesNoRentalN/A600TowingN/A5075100Vehicle 2 detailsZipVINVIN Override YearChoose...201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925ModelMakeStyleGaraging Address same as mailing?YesNoAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Lienholder/Additional Interest Name Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Vehicle History How long has the vehicle been registered in your name?Not registered in my name0-2 months3-6 months7-12 months1 - <2 years2 - <3 years3- <5 years5+ yearsUnknownAre you the first owner of the vehicleUnknownYesNoCompNo Coverage2505007501000UsePleasureTo and from workTo and from schoolArtisanBusiness useCollNo Coverage2505007501000Loss PayeeYesNoRentalN/A600TowingN/A5075100 CUSTOMARILY OPERATED VEHICLE(S)Driver 1: Driver-1Vehicle 1: vinDriver 2: Driver-2Vehicle 1: vinCoveragesBodily Injury:25000/50000Uninsured/Underinsured Motorist Limits:25000/50000Property Damage:2000025000Uninsured/Underinsured Motorist PD Limits:2000025000Income Loss Benefits:NoYesMedical Payments:No Coverage50010002000Additional Questions1. Are any drivers and/or vehicles located in Virginia less than 10 months per year?N/AYesNoAre any of the vehicles listed on this application registered to anyone other than the applicant (Named Insured), or the spouse of the applicant?N/AYesNo3. Are any vehicles listed on this application used for hire, commercial or business purposes, delivery, or in the course or scope of your employment?N/AYesNo4. Are any vehicles used in a carpool outside of Virginia, and/or do any drivers drive in a carpool or commute outside of Virginia?N/AYesNoNotes This iframe contains the logic required to handle AJAX powered Gravity Forms.
