� Generative summary Continue
Generative Al User Guidelines.
DocuSign Envelope ID: 5EE45F28-3534-44B1-A020-8CA81ED52D57 OKLAHOMA AUTOMOBILE APPLICATION
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P.O. Box 2014 • Shawnee Mission, KS 66201 Policy Number Effective Date & Time
Phone: 877-KEYINSCO' 877-539-4672 KOK4571244 01/11/21 4:42:08 PM CST
Name lnsured(s): Agency Number:
Erika Craycraft 9603
Address: Agency Name:
11925 S 101st East Ave Dorsey & Dorsey
Address2: Address: Phone:
6528 E 101st St 918-744-5145
City: State: Zip: City: State: Zip:
Bixby OK 74008 Tulsa OK 74133-6724
Email Address: �ne:
[Link] 9169173661
Garage: list lhe garaging location of all cars if different from address listed above. All cars must be garaged in Oklahoma. Territory
!
OK 6
List all licensed tesidenls, residents age l 4 and
older. and other OJ)efalors ineluding those with
ctxrently suspended or revoked drivefs licenses.
Date al Birth
Mo./OayfYr. Status Applicant """""
Marital s., Rela tionship t o Driver's License State License
Status
SR
22
Case No
ERIKA CRAYCRAFT 4/30/1986 V F Sel f d994328106 OK IDOnly
Describe below an Accidents, Arrests, Viotations, and Tickets durinq the past 3 years for All Residents andtor operators
Name of Driver Date Violations • Convictions • Accident Oe5ctiption
Description or Cars You Own
2013 FORD EXPLORER LIMITED (1FM5K7F88DGC71533) Symbol: 32 Business Use: NO
=-
Loss Payee / Additional Interest:
.cmterage Iimitcllasucaace
Bodily Injury Liability $25,000/$50,000 Each Person I Each Accident $32.00
Property Damage Liability $25,000 Each Accident $36.00
Total: $68.00
Coverage
Uninsured Motorist Rejected $0.00
Policy Fee: $10.00
Total: $78.00
PPA-OK (02-13)
DocuSign Enve lope ID: 5EE45F28-3534-44B1-A020-8CA81ED52D57 )igning)
1 Do you have existing damage on any of the veh icles included in this quote? YesO No0
2 Have all individuals residing in your household, 15 years old and older, been disclosed or excluded on thi s
application? If no, identify those individuals• Name, Dare of Birth. Orher Auto lnsUfance?
Yes(!] No □
3 Have all possible drivers, even those that may operate your vehicle on an infrequent basis been listed on th s
application? If no, explain:
i
Yes� No □
4 Are au vehicles in Ihe household listed on this application? If no, please explain: Yes� No □
5 Has any listed driver's or resident's license been suspended during the past 5 years? If yes, name driver and YesO No0
explain:
6 Has anyone in the household or any other regular operator been charged with a felony thaI resulted in a nolo YesO No[!]
comendere plea or verdict. plea bargained to a lesser charge or have any cases pending? If yes, thi s risk is
unacceptable.
7 Are any of your vehicles used for del ivery purposes, such as pizza or newspaper delivery, or for any business or YesO No[!]
commercial purposes, such as sales or marketing calls? If yes, type of business, I Trips/Day:
B Does anyone in househol d or any operator have a physical or mental impairment? If yes, describe: YesO No[!]
i
9 Do you or any of the listed drivers have a phys cal or mental impairment that may affect your/their ability to YesO No[!]
opernte an automobile, including but not limited to heart disease, diabetes. blackouts. seizure, or muscular
disorders, (If ·yes', submit unbound and a complete medical stalement is required at your expense.)
10 Is any vehicle titled or registered in any name other than the applicant and/or spouse? If yes. please explain: Ye, OS No
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APPLICANT TO INITIAL AFTER COMPLETING--'<:==:==j
Applicant's Employer _____________ Occupation Customer Service Representativ