Auto Insurance for International students – Get a free quote

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20%

General Information
Program
Risk State
Effective
Date Format: MM slash DD slash YYYY
Term:
Prior Coverage
Type
Prior Coverage Expiration
Date Format: MM slash DD slash YYYY
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Last Four of SSN
Last four of SSN recommended in order to provide the most accurate quote
Phone
Email
Home Owner
Time at Current Address
Years :
Months

Driver(s) Information
Number of drivers (Please get in touch with us if more than 2 drivers)
Driver 1
Relation
Name
First Last
DOB
Date Format: MM slash DD slash YYYY
Marital Status
Gender
License State
Driver's License Number
Years Licensed
License Status
Senior Defence Driver
SR-22
Completion Date
Date Format: MM slash DD slash YYYY
SR-22 Case
Number of incidents for driver 1
Incidents
Date
Date Format: MM slash DD slash YYYY
Incident
Date
Date Format: MM slash DD slash YYYY
Incident
Driver 2
Relation
Name
First Last
DOB
Date Format: MM slash DD slash YYYY
Marital Status
Gender
License State
Driver's License Number
Years Licensed
License Status
Senior Defence Driver
SR-22
Completion Date
Date Format: MM slash DD slash YYYY
SR-22 Case
Number of incidents for driver 2
Incidents
Date
Date Format: MM slash DD slash YYYY
Incident
Date
Date Format: MM slash DD slash YYYY
Incident
ADDITIONAL 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?
Has the Virginia license information been entered for all drivers who have held a Virginia license that has not expired or been permanently surrendered?

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)
Unlicensed Resident 1 details
Name
First Last
Relation
Occupation
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Unlicensed Resident 2 details
Name
First Last
Relation
Occupation
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Unlicensed Resident 3 details
Name
First Last
Relation
Occupation
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Unlicensed Resident 4 details
Name
First Last
Relation
Occupation
Date of Birth
Date Format: MM slash DD slash YYYY
Gender

VEHICLE(S) INFORMATION
Number of Vehicles (Please contact us if more than 2 vehicles)
Vehicle 1 details
Zip
VIN
VIN Override
Year
Model
Make
Style
Garaging
Address same as mailing?
- Yes
- No
Address
Street Address City State
Lienholder/Additional Interest
Name Address Line 2 City State ZIP Code
Vehicle History
How long has the vehicle been registered in your name?
Are you the first owner of the vehicle
Comp
Use
Coll
Loss Payee
Rental
Towing
Vehicle 2 details
Zip
VIN
VIN Override
Year
Model
Make
Style
Garaging
Address same as mailing?
- Yes
- No
Address
Street Address City State
Lienholder/Additional Interest
Name Address Line 2 City State ZIP Code
Vehicle History
How long has the vehicle been registered in your name?
Are you the first owner of the vehicle
Comp
Use
Coll
Loss Payee
Rental
Towing

CUSTOMARILY OPERATED VEHICLE(S)
Driver 1: Driver-1
Driver 2: Driver-2
Coverages
Bodily Injury:
Uninsured/Underinsured Motorist Limits:
Property Damage:
Uninsured/Underinsured Motorist PD Limits:
Income Loss Benefits:
Medical Payments:
Additional Questions
1. Are any drivers and/or vehicles located in Virginia less than 10 months per year?
Are any of the vehicles listed on this application registered to anyone other than the applicant (Named Insured), or the spouse of the applicant?
3. Are any vehicles listed on this application used for hire, commercial or business purposes, delivery, or in the course or scope of your employment?
4. Are any vehicles used in a carpool outside of Virginia, and/or do any drivers drive in a carpool or commute outside of Virginia?
Notes

Auto Insurance for International students – Get a free quote

Step 1 of 5

General Information

Prior Coverage

Time at Current Address

Driver(s) Information

Driver 1

Incidents

Driver 2

Incidents

Unlicensed Residents

VEHICLE(S) INFORMATION

Vehicle 1 details

Vehicle 2 details

CUSTOMARILY OPERATED VEHICLE(S)

Coverages

Additional Questions

Notes