Add a driver | Strata Insurance Group

First Name(Required)

Last Name(Required)

Email(Required)

Phone Number(Required)

Zip(Required)

Policy Information

Policy Information(Required)

Effective Date(Required)

Driver Information

Number of drivers to add(Required)

Driver 1

First name(Required)

Last Name(Required)

Social Security Number(Required)

Date of Birth(Required)

Gender(Required)

Marital Status(Required)

Relation to applicant(Required)

License Number(Required)

License State(Required)

License Status(Required)

Suspended in last 5 years?(Required)

Occupation Industry(Required)

Occupation title(Required)

Age Licensed(Required)

Please enter a number greater than or equal to 14.

Accident within 5 years?(Required)

Violation within 5 years?(Required)

SR22 filing?(Required)

Eligible for good student discount?(Required)

Eligible for defensive driver discount?(Required)

Eligible for driver's ed discount?(Required)

Driver 2

First name(Required)

Last Name(Required)

Gender(Required)

Marital Status(Required)

Relation to applicant(Required)

License Number(Required)

License State(Required)

License Status(Required)

Suspended in last 5 years?(Required)

Occupation Industry(Required)

Occupation title(Required)

Age Licensed(Required)

Please enter a number greater than or equal to 14.

Accident within 5 years?(Required)

Violation within 5 years?(Required)

SR22 filing?(Required)

Eligible for good student discount?(Required)

Eligible for defensive driver discount?(Required)

Eligible for driver's ed discount?(Required)

Review carefully: This is a solicitation for insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, email, voicemail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.