Henderson Insurance Services

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Insurance Limits
Liability
- 50/100
- 100/300
- 300/300
Comprehensive Deductible
- 500
- 1000
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Collision Deductible
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- 1000
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Medical
- 1000
- 2000
- 5000
- None
Roadside Assistance
- Yes
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Rental Coverage
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Expiration date of current policy
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How many drivers?
How many vehicles?
Do any of the Drivers have a college degree?
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Driver Information
Driver 1
Name
First Last
Date of Birth
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Drivers License Number
Date Issued
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Employer
Occupation
Employer Address
Street Address Address Line 2 City State ZIP Code
Name of School
School Address
Street Address Address Line 2 City State ZIP Code
Marital Status
Any DUI?
- Yes
- No
Driver 2
Name
First Last
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Date Issued
MM slash DD slash YYYY
Employer
Occupation
Employer Address
Street Address Address Line 2 City State ZIP Code
Name of School
School Address
Street Address Address Line 2 City State ZIP Code
Marital Status
Any DUI?
- Yes
- No
Driver Relationship To Insured
Driver 3
Name
First Last
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Date Issued
MM slash DD slash YYYY
Employer
Occupation
Employer Address
Street Address Address Line 2 City State ZIP Code
Name of School
School Address
Street Address Address Line 2 City State ZIP Code
Marital Status
Driver Relationship To Insured
Driver 4
Name
First Last
Date of Birth
MM slash DD slash YYYY
Drivers License Number
Date Issued
MM slash DD slash YYYY
Employer
Occupation
Employer Address
Street Address Address Line 2 City State ZIP Code
Name of School
School Address
Street Address Address Line 2 City State ZIP Code
Marital Status
Any DUI?
- Yes
- No
Driver Relationship To Insured
Vehicle Information
Vehicle 1
Year, Make, and Model
Vehicle Identification Number (VIN)
Use
- Work/School
- Pleasure
Current Odometer Reading
Expected Annual Mileage
Leased Or Financed?
- Leased
- Financed
Any Existing Damage?
- Yes
- No
Is the Vehicle A Rebuilt, Salvaged, Modified, Altered, or Special Built/Customized?
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Is the Vehicle Used For Uber Or Lyft?
- Yes
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Is the Vehicle Used For Delivery Purposes?
- Yes
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Registered Owner
First Last
Primary Driver
First Last
Vehicle 2
Year, Make, and Model
Vehicle Identification Number (VIN)
Use
- Work/School
- Pleasure
Current Odometer Reading
Expected Annual Mileage
Leased Or Financed?
- Leased
- Financed
Any Existing Damage?
- Yes
- No
Is the Vehicle A Rebuilt, Salvaged, Modified, Altered, or Special Built/Customized?
- Yes
- No
Is the Vehicle Used For Uber Or Lyft?
- Yes
- No
Is the Vehicle Used For Delivery Purposes?
- Yes
- No
Registered Owner
First Last
Primary Driver
First Last
Vehicle 3
Year, Make, and Model
Vehicle Identification Number (VIN)
Use
- Work/School
- Pleasure
Current Odometer Reading
Expected Annual Mileage
Leased Or Financed?
- Leased
- Financed
Any Existing Damage?
- Yes
- No
Is the Vehicle A Rebuilt, Salvaged, Modified, Altered, or Special Built/Customized?
- Yes
- No
Is the Vehicle Used For Uber Or Lyft?
- Yes
- No
Is the Vehicle Used For Delivery Purposes?
- Yes
- No
Registered Owner
First Last
Primary Driver
First Last
Vehicle 4
Year, Make, and Model
Vehicle Identification Number (VIN)
Use
- Work/School
- Pleasure
Current Odometer Reading
Expected Annual Mileage
Leased Or Financed?
- Leased
- Financed
Any Existing Damage?
- Yes
- No
Is the Vehicle A Rebuilt, Salvaged, Modified, Altered, or Special Built/Customized?
- Yes
- No
Is the Vehicle Used For Uber Or Lyft?
- Yes
- No
Is the Vehicle Used For Delivery Purposes?
- Yes
- No
Registered Owner
First Last
Primary Driver
First Last
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Founded in 1988, Henderson Insurance Services is an independent insurance brokerage. With hundreds of insurance companies to choose from, we find the best insurance plan to fit your specific needs. Let us do the shopping for you.

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Do You Need Earthquake Insurance?
Henderson Insurances Services | What are they and why do I need it?
Health Insurance – Open Enrollment 2018
What to do Before, During, and After an Earthquake
What to do after a car accident

Founded in 1988, Henderson Insurance Services is an independent insurance brokerage. With hundreds of insurance companies to choose from, we find the best insurance plan to fit your specific needs. Let us do the shopping for you.

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