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MICHIGAN! ARE YOU PAYING TOO MUCH FOR INSURANCE?? in Farmington Hills, Michigan

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Seller: David
Date/Time:26 Sep, 01:44 a.m. EST
Type: Services, For Sale - Private.

Deal with a Michigan based agency, not a lead aggregator for your auto insurance!
-MICHIGAN-AUTO INSURANCE QUOTE QUESTIONNAIRE
Please write clearly and fax, or email when completed.  Thank you. 
Tel. -248-848-xxxx Ext. 236; FAX 248-848-xxxx ATTN: DAVID- Lic Agent; Date Completed _______
Primary Insured Name:
Home Phone:
Address:
Work Number:
 
Email Address:
Garaging Address (if different)
Occupation:
 
Own or Rent your home?
Date of Birth:
 
Spouse Name:
 
Address (if different than above):
Alt Phone (i.e. cell)
 
Email Address:
Garaging Address (if different):
Occupation:
 
 
Spouse Date of Birth:
Spouse Work Number
Current Auto Insurance Company:
Renewal Date:
 
All Drivers living in house:Name/Date of Birth:
1.Name (as it appears on license)_____________________________ License # ________________ DOB:________
2.Name (as it appears on license)_____________________________ License # ________________ DOB_________
3.Name (as it appears on license)_____________________________ License # ________________ DOB__________
4.Name (as it appears on license)_____________________________ License # ________________ DOB___________
Any accidents in last 3 years?  Yes or No, if no any accidents in last 6 years?  Yes or No
Any minor moving violations (tickets) in last 3 years? Yes or No, if no any moving violations (tickets) in last 6 years?  Yes or No
Number of major violations (2 points) in last 3 years?  Yes or No, if no, any major violations in last 10 years?  Yes or No
 
Please explain any Yes answers below.  Include dates, what happened, type of violation.  Be as specific as possible and include whether you were at fault if it was an accident.
Driver # ______________________________________________________________________________________________
Driver # ______________________________________________________________________________________________
Driver # ______________________________________________________________________________________________
Driver # ______________________________________________________________________________________________
 VEHICLE INFORMATION-We also insure Motorcycles, Travel Trailers, Boats and Classic Cars!
                                                                                                                                                                                   
                       Yr/Make                 Model                              Body Style                          Miles: Wk/School         Vehicle Identification Number Mileage 
                                                                                                                                                                  
Car 1                ______________                ______________                ______________                ______________    _______________________________________   
Car 2                ______________                ______________                ______________                ______________    _______________________________________  
Car 3                ______________                ______________                ______________                ______________    _______________________________________  
 
Car 4                ______________                ______________                ______________                ______________    _______________________________________  
 Does an anti-theft device protect any of these vehicles?  Car No._____ Is the device     Manual        Automatic          VATS         Pass Key       Other
Any non standard (non factory) installed rims or other enhancements or special paint jobs?  If yes, please describe:
Is Homeowners policy with Farmers? Yes or No
Do any cars have air bags? _____________ Which cars? 1 2 3 4
Do any drivers under 25yrs have a "B" average with full time school units? ________Driver (s)________________________
Have any drivers taken a Senior Defensive Driving Course?  Driver(s) ______________________
 COVERAGES LIMITS:               
Bodily Injury Liability (Per Person/Per Accident) ______________              Property Damage_______________
Uninsured /Under Insured Liability  _____________________Motorist Medical_______________  (Per Person/Per Accident)
Medical Payments ___________ Mini Tort____________
Comprehensive (Other than Collision) Deductible____________                 Collision Deductible__________ 
Towing/Road Assistance (yes or no) _______
Rental Car Reimbursement (yes or no)_______ if yes, how much per day? ________.

State: Michigan  City: Farmington Hills  Zip code: 48334 Category: Services
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