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Applicants' Name:
Address:
City: State: Zip Code:
Phone: Fax:   Cell Phone:

Physical Damage: Deductible: Rate:
Liability: Limit:

VEHICLE INFORMATION:
Year: Make: VIN#: Current Value:


DRIVER INFORMATION:
Name: Years CDL: Date of Birth:
CDL #: State:


Be sure to read the statement below and check the box in affirmation of this statement. 

I authorized Great American Insurance/Classic Insurance Agency to obtain a copy of my Motor Vehicle Record rating/underwriting the insurance for which I have applied.  I agree that the foregoing statements and answers are true and a full exposition of the facts and circumstances with regard to the risk of the Insured, and these were used as a basis and condition of the insurance. By checking the box to the left, I affirm knowledge of and adherence to current DOT Safety regulations, and hereby apply for insurance with respect to the coverages states on this application.  I am aware that there is no coverage while engaging in commerce with this policy.