Rian' JUNE 1982 Orficulturisf ~ Ihis"Gbeg PREFERRED Un REQUEST Formisbroug..T 1 1 to YOU by AHS for YOUR BENERT
----..-RIaN' JUNE 1982 ORfICULTURISf ~ iHis"GBeG PREFERRED un REQUEST FORMisBRoUG..t 1 1 TO YOU BY AHS FOR YOUR BENERT. 1 Send to: GEICO PREFERRED, GEICO Plaza, Washongton, D.C. 20076 If student away at school, give distance from home 1 1 Name --miles Addres,>..s ___________________ ____ Apt.# ____ CAR 1 CAR2 CAR3 City. ________________ Stat,t:..e _______Zi,l'-p ____ Year & Make (Buick. 1 Dodge. etc.) 1 1 Phone( Model (Skylark. Omni. Name of current insurance company' ______________________ etc.) 1 1 Date present insurance expires Mo __ Yr. __Employer ___________ Yrs __ Body type: 2 dr., Sta. Wag .• etc. 1 Title / Grade..e ________________________Yrs. __ No. of cylinders 1 If in present occupation less than 2 yrs. or retired, give former occupation: 1 Est. Total Mileage 1------------------------ Est. Annual Mileage 1 1 Years at current addres,,-s _____________Previously insured by GEICO: Yes 0 No 0 Days per week driven to work. school or depot TraHic 1 Accidents Conviction license One way distance M Driver in Past in Past Suspen· 1 UstAIl Birthdate Marital or Percent of Use Trainin~ Years 5 years' 3 Years* sionO 1 Is car used in business Drivers Relation Mo. Day Yr. Status F Occupation Car 1 Car2 car 3 Yes No Driving Yes No Yes No Yes No except to/from wof1(?· 1 (Self) 1 car location if different than mail address: 1 City/ State 1 1 ' If "yes" explain 1 I >,'l For accidents , traffic convictions, or license suspension , give dates and complete details, including cost of damages. on a separate sheet.
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