High-Risk Vehicle Insurance Application Form
Full Name
Date of Birth
Phone Number
Email Address
Residential Address
Driver's License Number
License Status
Valid
Suspended
Expired
Vehicle Information
Vehicle Make
Vehicle Model
Year
Vehicle Identification Number (VIN)
Vehicle Use
Personal
Commercial
Rideshare
High-Risk Details
Reason for High-Risk Classification
Multiple Claims
Serious Violation
DUI/DWI
Previous Suspended License
High-Performance Vehicle
Other
Please Provide Details
Previous Insurer
Has your insurance ever been cancelled or non-renewed?
Yes
No
Additional Information