Robert Christy, Agent

Print this form and complete as much as possible before visiting our office.

Date_____________________________________

Name 1__________________________________

Birthdate_________________________________

SS#_____________________________________

DL#_____________________________________

Violations_________________________________

*SR22  YES  or  NO

Other licensed drivers in the house?________

_________________________________________

Address__________________________________

Phone#__________________________________

Prior Insurance____________________________

Vehicle #1_______________________________

VIN#____________________________________

Coverage-Liability Only or Full Coverage: Limits

________________________________________

Deductable: 100  250  500  1000

Vehicle #2____________________________________

VIN#__________________________________________

Coverage-Liability Only or Full Coverage: Limits

______________________________________________

Deductable:  100  250  500  1000

Vehicle #3____________________________________

Coverage-Liability Only or Full Coverage: Limits

______________________________________________

Deductable:  100  250  500  1000

NOTES:________________________________________

______________________________________________

______________________________________________

Any Questions?

Please Call

419-423-7061 or 800-352-2760

Referred by___________________________________

Name 2_______________________________________

Birthdate_______________________________________

SS#___________________________________________

DL#___________________________________________

Violations_______________________________________

*SR22  YES  OR  NO

______________________________________________

Other PH#______________________________________

Lapse Time_____________________________________

Changes in Ohio Driving Laws

Several changes to Ohio's driving laws - most aimed at 16 year-old drivers, were incorporated under House Bill 343, which went into effect April 3, 2007.

• 16 year-olds licensed in Ohio will be restricted to one non-family member passenger.
• 16 year-olds will be prohibited from driving between midnight and 6 a.m., instead of 1 to 5 a.m. Exceptions remain available for work and in emergencies.
• 16 year-olds who are convicted of a moving violation must be accompanied by a parent, or adult guardian until they reach 17. Currently, drivers 15 1/2 who have a learner's permit must ride with an adult until they are licensed to drive.
• Back-seat passengers 15 and under must be restrained by a seat belt, or booster seat.