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Uber & Lyft Auto Insurance
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Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
How Many Vehicles
*
1
Less than 5
More than 5
Driving Time
*
4 Hours or less per day
>4 hours but <8 hours
8 hours or more
Email
*
Contact Phone
*
Are you currently Insured
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Yes
No
If yes, Name of current insurance company
*
If Insured how long
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Less than 6 months
Less than 1 year
Greater than 1 year
Driver Age
*
Less than 25
Age 25 or Greater
Foreign Drivers License
*
No
Yes
Black Car Qualifed
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Yes
No
Vehicle Year
*
Vehicle Make
*
Vehicle Model
*
Vehicle VIN #
*
Vechicle Value
*
Driver Name
*
Drive-Date of Birth
*
Driver License Number
*
License State
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Driver-Maritial Status
*
Liability Limits Requested
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100,000 / 300,000 / 50,000
$500,000 CSL
Medical Payments
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$1,000
$5,000
$10,000
$50,000
Comprehensive Deductible
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$500
$1,000
$2,000
Collision Deductible
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$500
$1,000
$2,500
Vehicle Usage Information:
Which Type Driver
*
Uber Driver
Lyft Driver
Regular Taxi Driver
Airport Runs
*
No Airport Runs
Less than 80% of my runs are to the airport
80% or more of my runs are to airport
Radius of Operation
*
Enter the maximum one way mileage you travel on a regular basis for your work.
Bais of Pickups
*
Majority of my pick ups ARE NOT pre arranged
The majority of my pick ups ARE pre arranged
List Driver Violation & Accidents
*
Enter tickets and accidents for any driver who has had violations within the last three years.
Other notes you feel we need
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Upload File
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Max file size: 20MB
You can upload a copy of your current insurance coverage declaration page here.
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