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Date of Filing
Premium Receipt
Renewal of
Insured
Name
Address
TEL-Home
Mail
Office
Birthday
Age
Factor
Single /Married
S
M
Rank
Officer
E9
E8
E7
E6
E5
E4
E3
E2
E1
Civilian
Pay Grade
In Charge
Policy Term
Original Eff.
From
Time
Month
To
Credit Card
Description of Automobile
Year Model
Trade Name
Spec.
License Plate No.
Okinawa
Touhoku
Other
Car Type Code
Private Passenger Sedan (Large)
Private Passenger Sedan (Small)
Private Mini Sedan
Serial No
Next Inpsection
JCI Co.
JCI Exp.
JCI Pol.
Policy Data
New /Renew
Car Class
AO Misc
Grade
Code
Date
Memo
Premium
Coverage
Deductible
Limit of Liab.
Premium
A:Comprehensive
0
30,000
50,000
100,000
,000
B:Collision or Upset
0
30,000
50,000
100,000
,000
Loss of Use by Theft Rental Reimb.
0
1,800
3,600
C:Bodily Injury Liability
Default
,000
D:Property Damage Liability
,000
E:Medical Payments
0
90,000
180,000
270,000
360,000
720,000
Declarations
Gross Prem.
Sports car
Applied Disc.
Net Prem.
Minimum Prem
Short Rate
Total Prem.
Item5
Amt. of Enc.
Due date of Final Note
Item8
Status:
Message:
UC-001 Calc Prem
UC-002 Save Quote
UC-003 Get Quote
Default Data
uiData:
{}
Declarations
×
1. Declaration of the Youthful Drivers Covered
Is there any youthful driver aged 20 or under residing with you?
1: YES 2: NO Space: None
2. Has any accident occurred during the last 12 months?
If yes, please specify.
1: YES 2: NO Space: None
Property Damage Loss
times
Bodily Injury Loss
times
3. Has any automobile policy expired or been cancelled during last 12 months?
1: YES 2: NO Space: None
Insurance Company
1: AIU 2: ACE 3: Other
Policy Number
4. Has any automobile policy been demerit-rated any insurance company?
1: YES 2: NO Space: None