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Add A Driver To Your Policy
Name:
E-mail Address:
Policy Number:
   

Driver Information
Name (as it appears on license):
Date of birth for added driver:
Driver's license number for driver:
State driver is licensed in:
License status:
   

Has this driver (explain any 'yes' answer in remarks section):
Ever been treated for epilepsy, diabetes, heart condition, mental illness or impairment? If yes, give details including date:
Any physical impairment or deformity?   If yes, give details including date:
A history of fainting, loss of consciousness, blackouts, seizures or convulsions:  If yes, give details:
Had his/her driver's license suspended or revoked within the past 3 years? If yes, give details including date:
A restricted or expired driver's license? If yes, give details including date:
Had auto insurance cancelled, declined or renewal refused in the last 3 years? If yes, give details including date:
Been convicted of any moving traffic violations in the past 3 years (violations dismissed by traffic school do not count)?   If yes, give details including date:
Ever been convicted of:
bulletDriving while drinking,
bulletOpen bottle,
bulletPossession of alcohol,
bulletDrunk in auto,
bulletDrunk in public,
bulletHit & run,
bulletReckless driving, or
bulletRefusal to submit to an intoximeter test?
Ever been convicted for use or possession of drugs or being present where narcotics are being used? If yes, give details including date:
Ever been convicted of a criminal offense? If yes, give details including date:
Been involved in any at-fault accidents in the past 5 years? If yes, give details including date:
Been involved in any at not-at-fault accidents in the past 5 years? If yes, give details including date:
Had a motor vehicle stolen in the past 5 years? If yes, give details including date:
Any other losses (claims) paid by your insurance company in the past 5 years? If yes, give details including date:
Additional Remarks:

*IMPORTANT!*
No change is made until you receive an e-mail from us indicating that the change is complete.  DO NOT let the added driver operate your vehicle(s) until you have received a confirming e-mail from us.

 

 

Kennedy Professional Insurance Agency
P.O. Box 847
19167 Highway 18, Suite 1
Apple Valley, CA  92307
(760) 242-2345 Phone
(760) 242-2211 Fax
kpia@kpia.com
License#:  0B44021
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