| MARRIED SINGLE |
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| |
| MODEL YEAR |
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| MAKE (Chev, NISSAN..) |
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| MODEL & DESIGNATION |
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| Is car driven to
work? |
Y / N |
Y / N |
Y / N |
Y / N |
| COLLISION | Y / N |
Y / N |
Y / N |
Y / N |
| Liability Limits (Injury) |
| |||
| MALE DRIVERS |
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| FEMALE DRIVERS |
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Has Any Member Of Your Household Had Any
Accidents Or Tickets In The Past 3½ Years? Y N
If Yes How Many? ____________ What Type & When
_____________________________
__________________________________________________________________________
What Company Currently With? __________________ Renewal Date
_________________
A representative of Your Agency will call you tomorrow. Please have
your current policy "on hand" so that the agent can make an accurate
comparison.
BEST TIME TO CALL
________________________________________________________
Caller______________________________________Date____________________________
SPOKE TO:
Mr./s./
_______________________________________________________
First
Last
Call Date
Representative
NOTES