Simply Drive Participation Agreement Presented By Countryfinancial PDF

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a good description of chapters from the textbook to help you out on this test thanks...

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Simply DriveSM Teen Driver Discount Participation Agreement

COUNTRY Mutual Insurance Company® COUNTRY Preferred Insurance Company® COUNTRY Casualty Insurance Company® PO Box 2100, Bloomington, IL 61702-2100

Congratulations on completing the Simply Drive online course! Please complete the top half of this form and bring it to your representative's office along with at least one parent/guardian. Don't forget to ask about our Good Student Discount Program as well! TEEN FIRST NAME

MIDDLE INITIAL

LAST NAME

DATE OF BIRTH

• • • •

I will obey rules of the road and all traffic laws. I will always wear my seat belt while driving, as required by law. I will make sure my passengers wear their safety belts. I will never drive under the influence of alcohol or drugs, or ride with a driver who is under the influence of alcohol or drugs. • I will limit distractions while driving including use of mobile devices, eating/drinking and adjusting car stereo/GPS. Other than your parents or legal guardians, please list any household residents who may be passengers while you are driving. FIRST NAME

MIDDLE INITIAL

LAST NAME

DATE OF BIRTH

GENDER

TO BE COMPLETED IN THE REPRESENTATIVE’S OFFICE WITHIN 45 DAYS OF THE COMPLETION OF THE COURSE. I understand and agree to these driving conditions and rules. I have completed the Simply Drive online course and met with my representative on , 20 at : am/pm. Certain convictions or accidents by the teen driver may result in loss of the discount associated with the Simply Drive program.

Teen Driver Signature

Date

Parent/Guardian Signature

Date

Representative or Assistant Signature (optional)

Date

POLICY NUMBER

11058a (03-01/19)

AGENT NO.

REPRESENTATIVE NAME

INSURANCE OFFICE...