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CAMACHO SCHOLARSHIP FOUNDATION

Guam scenery with waves.

Auto Insurance Application

* Required field

Leave me blank for Auto Insurance Application.

Which center would you prefer to apply at? *

Tamuning

Dededo

First Name *

Middle Initial

Last Name *

SSN *

Date of Birth *

Driver's License Number

Mailing Address *

Home Address

Home Phone *

Work Phone

Model / Year

Trade Name

VIN No. & Motor No.

Body Type

No. of Cylinders

Vehicle Condition

New

Used

Date Purchased

Present Value

Car Radio

Car Radio Feature Amount

A/C

A/C Feature Amount

Louvers

Louvers Feature Amount

Mag-Wheels

Mag-Wheels Feature Amount

Stereo & Accessories

Stereo & Accessories Feature Amount

Other Accessories

Other Accessories Description

Other Accessories Feature Amount

What is the principal use of the vehicle?

Pleasure or Non-Business

Business Purposes

Other

The geographical use of this vehicle is Guam. If other, specify

Driver 1

Driver 1 Name

Driver 1 Relationship to Applicant

Driver 1 Date of Birth

Driver 1 Marital Status

Driver 1 Occupation

Driver 1 Length of Time Driving

Driver 1's License No. & State

Driver 1 Percentage of use

Driver 2

Driver 2 Name

Driver 2 Relationship to Applicant

Driver 2 Date of Birth

Driver 2 Marital Status

Driver 2 Occupation

Driver 2 Length of Time Driving

Driver 2's License No. & State

Driver 2 Percentage of use

Driver 3

Driver 3 Name

Driver 3 Relationship to Applicant

Driver 3 Date of Birth

Driver 3 Marital Status

Driver 3 Occupation

Driver 3 Length of Time Driving

Driver 3's License No. & State

Driver 3 Percentage of use

Driver 4

Driver 4 Name

Driver 4 Relationship to Applicant

Driver 4 Date of Birth

Driver 4 Marital Status

Driver 4 Occupation

Driver 4 Length of Time Driving

Driver 4's License No. & State

Driver 4 Percentage of use

Driver 5

Driver 5 Name

Driver 5 Relationship to Applicant

Driver 5 Date of Birth

Driver 5 Marital Status

Driver 5 Occupation

Driver 5 Length of Time Driving

Driver 5's License No. & State

Driver 5 Percentage of use

Had automobile insurance declined, canceled or renewal refused?

Yes

No

Had his/her driver's license or permit revoked, suspended or restricted?

Yes

No

Had a moving violation within the last three years or been convicted of driving under the influence of alcohol or harmful drugs?

Yes

No

Had an accident (as a driver) within the last three years?

Yes

No

Had or continued to have a physical or mental deficiency or impairment?

Yes

No

Please give name and policy number of previous insurance company

Please give estimate of annual mileage of insured vehicle(s)

Comment

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