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Additional Drivers
Additional Driver
Driver History
Name
First Name
Last Name
Gender
*
Male
Female
Date of birth
*
MM
DD
YYYY
Marital Status
*
Married
Single
Domestic Partner
Separated
Widowed
Divorced
Relationship to Driver 1
*
Child
Parent
Significant other
Fiancé
Friend / Roomate
Other
U.S License Status
Valid
Permit
Suspended
Permanently revoked
Expired
Not Licensed
Commerical / Business
Foreign License
Years Licensed
3 years or more
At least 2 years, but less than 3 years
At least 1 year, but less than 2 years
Less than a year
Tickets or Violations?
Yes
No
Violation Type
ACCIDENT
ACCIDENT NOT AT FAULT
ACCIDENT/CARELESS
ACCIDENT/DRAG RACING
ACCIDENT/ DUD
ACCIDENT/ DWI
ACCIDENT/ MINOR
ACCIDENT/ RECKLESS
CARELESS DRIVING
COMP. CLAIM
DEFECTIVE EQUIPMENT
DRIV LEFT OF CENTER
DRIV UNDER DRUGS
DRIV W/O OWNER CONSENT
DRIV WHILE DISTRACTED
DRIV WHILE INTOX
DRIVING W/O INSURANCE
DRIVING W/O LICENSE
ELDUING POLICE
FAILURE TO CONTROL VEH
FAIL TO YIELD TO PED.
FAILURE TO REPORT
FAILURE TO YIELD
FELONY HOMICIDE
FELONY MOTOR VEHICLE
FOLLOWING TOO CLOSE
FRAUD SECURING LIC
HIT AND RUN
HIT & AMP; RUN WITH BOD. INJ
ILLEGAL PASSING
IMP. CHILD RESTRAINT
IMPLIED CONSENT
IMPROPER BACKING
IMPROPER LANE CHANGE
IMPROPER LANE USE
IMPROPER PASSING
IMPROPER TURN
IMPRUDENT SPEEDING
LEAVING SCENE OF ACC.
LENDING DRIVERS LIC
LIC RESTRICTION VIOL
LITTERING
MANSLAUGHTER
MINOR (OTHER)
OBSTRUCTING AN OFFICER
OPEN CONTAINER VIOL
PASSING SCHOOL BUS
RACING | DRAG RACING
RECKLESS DRIVING
REVOKED OR SUS. LIC.
RUNNING RED LIGHT
RUNNING STOP SIGN
SEAT BELT
SPEED IN SCHOOL ZONE
TOO FAST FOR CONDITION
TRANSPORTING LIQ|DRUG
UNSAFE FROM PARKED
UNVERIFIABLE DRIV REC
WRONG SIDE OF ROAD
WRONG SIDE ON ONE WAY
If yes, when?
MM
DD
YYYY
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