Insurance

CHRISTENSEN

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860-651-8236

Email Address

DRIVER 3: name-- date of birth-- license number and state-- social security number--occupation--age licensed

VIOLATIONS & ACCIDENTS: driver--date of occurance--type of occurance--amount paid out--were you at fault?

Discounts

VEHICLE 3: year--make--model--VIN#--annual miles--miles to work--place of employment--anti theft?--loan or lease?--work or pleasure?--primary driver

DRIVER 4: name-- date of birth-- license number and state-- social security number--occupation--age licensed

DRIVER 2:name-- date of birth-- license number and state-- social security number--occupation--age licensed

Violations &

Accidents

Desired bodily injury coverage or current coverage *

25,000/50,000 100,000/300,000 unsure

Residence

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Completed driver's education training

Good student for school aged drivers

One or more drivers are away at school or college

Completed 55 Alive Course

Smoker

Non smoker

Address *

VEHICLE 2: year--make--model--VIN#--annual miles--miles to work--place of employment--anti theft?--loan or lease?--work or pleasure?--primary driver

Primary Phone Number *

Residence type *

Own condo Rent home Rent apartment

Address

Upload a current

or past policy

General Information

VEHICLE 4: year--make--model--VIN#--annual miles--miles to work--place of employment--anti theft?--loan or lease?--work or pleasure?--primary driver

Comments

Comments and Questions

Full Name

Contact Numbers

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Previous address if you have been at current address for less than 6 months

First and Last Name *

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AAA member

AARP member

Vehicles

Drivers

Previous/Current Insurance Carrier

Email *

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Desired property damage coverage/ or current coverage *

20,000 50,000 250,000 unsure or other

Upload a copy of a current or past policy

Year of membership for AAA or AARP

Accident Deductable *

250 1000 unsure

Secondary Phone Number

Coverages

DRIVER 1: name-- date of birth-- license number and state-- social security number--occupation--age licensed *

VEHICLE 1: year--make--model--VIN#--annual miles--miles to work--place of employment--anti theft?--loan or lease?--work or pleasure?--primary driver *

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