| *
Required |
This quote
is for an estimate only and does not give any coverage. Actual
policy coverage and premiums my differ or not be provided
after underwriting review. |
|
Currently
Insured By: |
Company
Name |
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Current
Policy Expires: |
Month/Year |
| * |
First Name |
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| |
Middle
Initial |
|
| * |
Last Name |
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| |
Business
Name |
|
| |
Business
Type |
|
| |
Street
Address |
|
| |
City |
|
| |
State |
|
| |
Zip |
|
| |
Home Phone |
|
| |
Cell Phone |
|
| |
Business
Phone |
|
| * |
Email
Address |
|
|
I
prefer to be contacted by: |
|
| * |
I grant Interlakes Insurance permission
to secure your credit and/or claim history, for insurance
purposes only, under the Fair Credit Reporting Act. |
|
Automobile
Quote: |
|
List
family drivers by first and last name, sex, birth date and
driver's license number |
|
|
Name |
Birth
Date |
Male
/ Female |
Drivers
Lic # |
| |
Driver
1 |
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Driver
2 |
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Driver
3 |
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Driver
4 |
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Driver
5 |
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|
List
year, make, model, name of main driver (ie. 2004, GMC, Envoy,
Mark), annual miles, Vin # & Usage |
|
|
Year |
Make |
Main
Driver |
Model |
Annual
Miles |
Use
Type |
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Auto
1 |
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Auto
2 |
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Auto
3 |
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Auto
4 |
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List
Current Vehicle Coverage |
|
Comprehensive
Deductible |
|
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Collision
Deductible |
|
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Liability
Limits: |
|
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Bodily
Injury Liability |
|
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Property
Damage Liability |
|
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Uninsured
Motorist Bodily Injury Liability |
|
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Underinsured
Motorist Liability: |
|
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Personal
Property Insurance |
Dollar
Amount |
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Limited
Property Damage |
Dollar
Amount |
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Personal
Injury Protection |
|
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Rental
Car |
|
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Road
Service |
|
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Any
tickets or accidents by the above listed drivers within the
last 5 years |
|
|
If
yes to the above, please describe |
|
|
Enter
any additional comments or questions here |
|
| |
This quote
is for an estimate only and does not give any coverage. Actual
policy coverage and premiums my differ or not be provided
after underwriting review. |
