Advantage Insurance Group Auto Quote Questionnaire
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| Applicant Name
*
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| Address
*
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| Home Status (required for certain company discounts)
*
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| Home Phone
*
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| Cell Phone
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| Email
*
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| Applicant Date of Birth
*
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| Applicant Social Security #
*
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| Applicant Drivers License State and #
*
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| Spouse Name
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| Spouse Date of Birth
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| Spouse Social Security #
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| Spouse Drivers License State and #
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Auto Information
A description of the section goes here.
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| Year, Make, Model of vehicle 1
*
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| VIN # for Vehicle 1
*
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| Driver of Vehicle 1
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| Comprehensive/Collision coverage with deductible for Vehicle 1?
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| Year, Make, Model of Vehicle 2
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| VIN # for Vehicle 2
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| Driver of Vehicle 2
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| Comprehensive/Collision coverage with deductible for Vehicle 2?
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| Requested liability limits (our agency minimum is $50,000/$100,000). This limit applies to all vehicles.
*
| 50,000/100,000 100,000/300,000 250,000/500,000
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| Please list any claims, tickets, and accidents. Put the driver and vehicle involved, along with the type of incident and date of occurance.
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| Is the vehicle currently insured?
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| Yes No New Purchase
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| Current Insurance Provider
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| Expiration date of current policy
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| Please list any other household drivers with DOB, SS# & DL#. Also list any additional vehicles with VIN or submit a second form and note the additional submission.
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