Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
QUOTE UPDATE
1STOP Insurance Agency
Current Company
Policy #
Quoted Company (If Different)
Quote #
Customer Name
First Name
Last Name
Zip Code
Current (6 Month Premium / Monthly)
Proposed (6 Month Premium / Monthly)
What is your recommendation
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Switch to new policy
Stay with current
Other
If other (please explain)
Please state any other important information
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