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Brunei
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Burkina Faso
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Cameroon
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Cape Verde
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Chad
Chile
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Christmas Island
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Democratic Republic of the Congo
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El Salvador
Equatorial Guinea
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Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
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Guinea
Guinea-Bissau
Guyana
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Hong Kong
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India
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Iran
Iraq
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Israel
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Japan
Jersey
Jordan
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Kenya
Kiribati
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Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
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Malawi
Malaysia
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Niue
Norfolk Island
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Northern Mariana
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Pakistan
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Panama
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Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
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Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Sierra Leone
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Slovakia
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South Ossetia
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6
What insurance coverage are you looking for?
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Auto / Home / Life
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7
Questions about your Home...
What Year was your Home Built?
What is your total Square Footage?
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8
What type of Roof is on your Home?
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How old is your current Roof?
Select how old your roof is...
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10
How is your Home Constructed?
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11
What is your Foundation Type?
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12
Do you have a Swimming Pool?
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13
Do you have a Trampoline?
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14
Do you have any Pets?
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Yes
No
No
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Yes
No
If YES, what type of pets & breed?
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15
Do you want to get a quote for Auto Insurance?
Bundling your Homeowners Insurance with an Auto Policy gets you extra savings!
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16
Information about Driver #1
What is your Driver's License #
What is your Date of Birth?
What is your SSN# ?
Please Select
None
1 Accident or Violation
2 Accidents or Violations
3 Accidents or Violations
4+ Accidents or Violations
None
Please Select
None
1 Accident or Violation
2 Accidents or Violations
3 Accidents or Violations
4+ Accidents or Violations
Have you had any Accidents or Violations in the past 5 yrs?
Miles to Work?
Miles Driven Each Year?
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To/From Work
Business
Farm/Ranch
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Pleasure
To/From Work
Business
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Primary Use of Vehicle?
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17
Information about Driver #2
Is there another person to add to the Auto Policy?
Please Select
No
Yes
No
Please Select
No
Yes
Are you wanting to insure another driver?
What is the driver's name?
What is their Driver's License #
What is their Date of Birth?
What is their SSN# ?
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None
1 Accident or Violation
2 Accidents or Violations
3 Accidents or Violations
4+ Accidents or Violations
None
Please Select
None
1 Accident or Violation
2 Accidents or Violations
3 Accidents or Violations
4+ Accidents or Violations
Have they had any Accidents or Violations in the past 5 yrs?
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Option 1
Option 2
Option 3
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Please Select
Option 1
Option 2
Option 3
Miles to Work?
Miles Driven Each Year?
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18
Information about Driver #3
Is there another person to add to the Auto Policy?
Please Select
No
Yes
No
Please Select
No
Yes
Are you wanting to insure another driver?
What is the driver's name?
What is their Driver's License #
What is their Date of Birth?
What is their SSN# ?
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None
1 Accident or Violation
2 Accidents or Violations
3 Accidents or Violations
4+ Accidents or Violations
None
Please Select
None
1 Accident or Violation
2 Accidents or Violations
3 Accidents or Violations
4+ Accidents or Violations
Have they had any accidents or violations in past 5 years?
Miles to Work?
Miles Driven Each Year?
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19
Information about Driver #4
Is there another person to add to the Auto Policy?
Please Select
No
Yes
No
Please Select
No
Yes
Are you wanting to insure another driver?
What is the driver's name?
What is their Driver's License #
What is their Date of Birth?
What is their SSN# ?
Please Select
None
1 Accident or Violation
2 Accidents or Violations
3 Accidents or Violations
4+ Accidents or Violations
None
Please Select
None
1 Accident or Violation
2 Accidents or Violations
3 Accidents or Violations
4+ Accidents or Violations
Have they had any accidents or violations in past 5 years?
Miles to Work?
Miles Driven Each Year?
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20
Add a Vehicle
Enter the VIN # (or) Year, Make, Model, and Body Style
Please enter vehicle VIN number
Please Select
Comprehensive Coverage
Collision Coverage
Please Select
Please Select
Comprehensive Coverage
Collision Coverage
Type of Coverage
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Body Style
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21
Add a 2nd Vehicle
Enter the VIN # (or) Year, Make, Model, and Body Style
Please Select
No
Yes
No
Please Select
No
Yes
Are you wanting to insure another vehicle?
Please enter vehicle VIN number
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Body Style
Please Select
Comprehensive Coverage
Collision Coverage
Please Select
Please Select
Comprehensive Coverage
Collision Coverage
Type of Coverage
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22
Add a 3rd Vehicle
Enter the VIN # (or) Year, Make, Model, and Body Style
Please Select
No
Yes
No
Please Select
No
Yes
Are you wanting to insure another vehicle?
Please enter vehicle VIN number
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Body Style
Please Select
Comprehensive Coverage
Collision Coverage
Please Select
Please Select
Comprehensive Coverage
Collision Coverage
Type of Coverage
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23
Add a 4th Vehicle
Enter the VIN # (or) Year, Make, Model, and Body Style
Please Select
No
Yes
No
Please Select
No
Yes
Are you wanting to insure another vehicle?
Please enter vehicle VIN number
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Body Style
Please Select
Comprehensive Coverage
Collision Coverage
Please Select
Please Select
Comprehensive Coverage
Collision Coverage
Type of Coverage
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24
Would you like Comprehensive and Collision coverage on all Vehicles?
YES
NO
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25
What Coverage Type are you looking for?
State Minim
State Minimum
Preferred
Basic
Hanby 5-Star Coverage
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26
What Comprehensive Deductible are you looking for?
Please select an amount
No Coverage
$100
$200
$250
$500
$1,000
$2,000
No Coverage
$100
$200
$250
$500
$1,000
$2,000
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27
What Collision Deductible are you looking for?
Please select an amount
No Coverage
$100
$200
$250
$500
$1,000
$2,000
No Coverage
$100
$200
$250
$500
$1,000
$2,000
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28
Do you want to get a quote for Life Insurance?
YES
NO
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29
Who do you want Life Insurance for?
Choose one or both
Myself
My Spouse
My Children
All of the Above
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30
What Life Insurance Term you are looking for?
Select Length of Policy...
10 Years
15 Years
20 Years
25 Years
30 Years
Whole Life
Universal Life
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31
What Coverage Amount per Policy?
Select amount of Coverage...
$75,000
$150,000
$250,000
$300,000
$500,000
$750,000
$1,000,000
$5,000,000
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32
What Start Date do you want your Insurance Coverage to Begin?
*
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-
Date
Month
Day
Year
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33
Who referred you to Hanby Insurance?
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