Provide information for ALL
licensed residents living in your household.
**this information is optional -(used to determine eligibility for preferred program)
Please list all accidents and violations below. The list should include approximate
dates, points, description, and amount paid by your insurance company to you or
another party. For example: 10/4/99 speeding ticket 13 miles over the limit for 2
points. or 5/1/00 I rear ended another party and my company paid them $1300.