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Aviza Agency – Coldwater, MI
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Kirgis Agency – Ionia, MI
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Auto Quote Coldwater

Customer Info:

Full Name:*

Phone Number:

Email Address:*

Address:*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

1/4

Vehicle #1 Year:

Vehicle #1 Model:

Vehicle #1 Make:

Vehicle #1 Vehicle ID#:

Vehicle #2 Info:

Vehicle #2 Year:

Vehicle #2 Make:

Vehicle #2 Model:

Vehicle #2 Vehicle ID#:

Vehicle #3 Info:

Vehicle #3 Year:

Vehicle #3 Make:

Vehicle #3 Vehicle ID#:

Vehicle #3 Model:

Driver#1 Name:

First

Last

Driver#1 DOB:

day

/

month

/

year

Driver#1 License#:

Driver#1 Vehicle Driven For:

Driver#1 How many miles one way?:

Driver#1 Do you have health insurance?:

Yes

No

Driver#1 Tickets or accidents in the last 3 years?:

Yes

No

Driver#1 If yes, what kind and date of occurrence:

Driver #2 Info:

Driver#2 Name:

First

Last

Driver#2 DOB:

day

/

month

/

year

Driver#2 License#:

Driver#2 Vehicle Driven For:

Driver#2 How many miles one way?:

Driver#2 Do you have health insurance?:

Yes

No

Driver#2 Tickets or accidents in the last 3 years?:

Yes

No

Driver#2 If yes, what kind and date of occurrence:

Driver #3 Info:

Driver#3 Name:

First

Last

Driver#3 DOB:

day

/

month

/

year

Driver#3 License#:

Driver#3 Vehicle Driven For:

Driver#3 How many miles one way?:

Driver#3 Do you have health insurance?:

Yes

No

Driver#3 Tickets or accidents in the last 3 years?:

Yes

No

Driver#3 If yes, what kind and date of occurrence:

Member of any groups?:

Senior

College Gradate

Credit Union

Professional (teacher, engineers, CPA, doctor)

Other

Current Insurance Company?:

Current Bodily liability limits?:

50/100

100/300

250/500

500/500

Other

Deductible

Comprehension Deductible

Vehicle 1:

Vehicle 2:

Vehicle 3:

Collision Deductible:

Home Owner:

Yes

No

Roadside/Towing:

Yes

No

Rental Reimbursement:

Yes

No

Additional Comment:

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A+ Insurance Associates, Inc.

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Ionia
Highland
Coldwater
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Auto Quote Coldwater

Customer Info:

Vehicle #1 Info:

Vehicle #2 Info:

Vehicle #3 Info:

Driver #1 Info:

Driver #2 Info:

Driver #3 Info:

Additional Information:

Deductible