Accident Information

Arrest information (This Incident)


Other offense information

If you were charged with any traffic offenses or crimes other than DUI, give the following information on EACH seperate offense:
Offense 1:
Were you aware that you committed this offense?
Any witnesses or evidence relating to this offense that supports your claim of innocence?
Offense 2:
Were you aware that you committed this offense?
Any witnesses or evidence relating to this offense that supports your claim of innocence?

Arrest history

Charge 1:
Charge 2:
Charge 3:
Charge 4:
Charge 5:

Automobile accidents where you were driving in the last 12 months?
Five years before that?

Information about vehicle driven at time of arrest

Liability Car Insurance on date of arrest?
Policy period at the time of your arrest:
Did you own the vehicle you were driving?
If you were not the owner of the vehicle you were driving at the time of the arrest, did you have liability insurance on another vehicle on the date of your arrest?
Policy Period at the time of your arrest:
If you did not have insurance at the time of your arrest, have your purchased it since?
If yes please provide:
Policy Period from the time of your arrest:
Have you investigated the cost of insurance in the event of a DUI conviction?

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