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Get State Farm 135-3776 a.6 2008

State Farm Mutual Automobile Insurance Company State Farm Indemnity Company State Farm Fire and Casualty Company Statement For Qualification For Steer Clear Discount Policyholder s Name Qualifying Driver s Name s Policy Number STEER CLEAR DISCOUNT INITIAL REQUIREMENTS 1. Ll private passenger automobiles in the household are insured with State Farm Mutual Automobile Insurance A C ompany State Farm Fire and Casualty Company State Farm Indemnity Company and or State Farm Guaranty Company. TO MAINTAIN STEER CLEAR DISCOUNT APPLICANT S STATEMENT I have met the initial requirements for the Steer Clear safe driver discount and understand that I will lose the discount if I am involved in an at-fault accident or receive a traffic violation. The discount will also be removed when I am 25 years old or sooner if I am classified as an adult prior to that age. TO MAINTAIN STEER CLEAR DISCOUNT APPLICANT S STATEMENT I have met the initial requirements for the Steer Clear safe driver discount and understand that I will lose the discount if I am involved in an at-fault accident or receive a traffic violation. The discount will also be removed when I am 25 years old or sooner if I am classified as an adult prior to that age. Signature of Qualifying Driver Date Signature of Parent/Guardian/Named Insured if qualifying driver is under age 18 Agent s Name and Code In some states certain accidents and moving violations may not disqualify you. Qualifying driver s have maintained an accident-free and moving violation-free driving record in the past three years 3. ll private passenger automobiles in the household are insured with State Farm Mutual Automobile Insurance A C ompany State Farm Fire and Casualty Company State Farm Indemnity Company and or State Farm Guaranty Company. Signature of Qualifying Driver Date Signature of Parent/Guardian/Named Insured if qualifying driver is under age 18 Agent s Name and Code In some states certain accidents and moving violations may not disqualify you. Qualifying driver s have maintained an accident-free and moving violation-free driving record in the past three years 3. ll private passenger automobiles in the household are insured with State Farm Mutual Automobile Insurance A C ompany State Farm Fire and Casualty Company State Farm Indemnity Company and or State Farm Guaranty Company. .

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