Garber Atlas Fries & Associates, Inc. - Auto Insurance Form

Insured Information
Insured Name:*
Address:
City:
State/Province:
Zip/Postal Code:
Phone:
Email:*

Current Insurance
Do you presently have Auto Insurance?

YesNo
Company Name
Renewal Date
Annual Premium
Have you been cancelled or non-renewed in the past 3 years?

YesNo

Coverages
Bodily Injury Liability
Property Damage Liability
Personal Injury protection
Uninsured Motorist Liability
Uninsured Motorist Property
Underinsured Motorist Liability
Underinsured Motorist Property
Comprehensive Deductible
Collision Deductible
Rental Reimbursement

YesNo
Towing & Labor

YesNo

Licensed Drivers
1. (Primary Driver)

Other Drivers

Vehicles(s) Information

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Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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