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Your contact information: (*) - required fields.
*First Name:
*Last Name:
*Phone:
*Address:
*City:
*State:
*Zip:
Cell Phone:
Driver #1
*Name (first, last):
*Date of Birth:
In The Last 3 Years Have You Had:
Any Tickets?: No Yes - How many?
Any Accidents?: No Yes - How many?
Any Major Traffic Violations?:
If for a motorcycle, do you have a motorcyle license: No Yes
Have you taken a motorcycle safety course?: No Yes
Vehicle #1:
*Year:
*Make:
*Model:
For Motorcycle: CCs?
For Boat:
Horse PowerLengthMax SpeedPropulsionValue
TrailerYearLength
No
Yes
Coverage Desired: Liability Basic Full Coverage Package
Premier Full Coverage Package
*Is there Coverage In Place Now?:
No Yes, fill in below:
CompanyAnnual PremiumType of CoverageExpiration Date
Driver #2
Name (first, last):
Date of Birth:
In The Last 3 Years Have You Had:
Any Tickets?: No Yes - How many?
Any Accidents?: No Yes - How many?
Any Major Traffic Violations?:
If for a motorcycle, do you have a motorcyle license: No Yes
Have you taken a motorcycle safety course?: No Yes
Vehicle #2:
Year:
Make:
Model:
For Motorcycle: CCs?
For Boat:
Horse PowerLengthMax SpeedPropulsionValue
TrailerYearLength
No
Yes
Coverage Desired: Liability Basic Full Coverage Package
Premier Full Coverage Package
Is there Coverage In Place Now?:
No Yes, fill in below:
CompanyAnnual PremiumType of CoverageExpiration Date
Driver #3
Name (first, last):
Date of Birth:
In The Last 3 Years Have You Had:
Any Tickets?: No Yes - How many?
Any Accidents?: No Yes - How many?
Any Major Traffic Violations?:
If for a motorcycle, do you have a motorcyle license: No Yes
Have you taken a motorcycle safety course?: No Yes
Vehicle #3:
Year:
Make:
Model:
For Motorcycle: CCs?
For Boat:
Horse PowerLengthMax SpeedPropulsionValue
TrailerYearLength
No
Yes
Coverage Desired: Liability Basic Full Coverage Package
Premier Full Coverage Package
Is there Coverage In Place Now?:
No Yes, fill in below:
CompanyAnnual PremiumType of CoverageExpiration Date
Driver #4
Name (first, last):
Date of Birth:
In The Last 3 Years Have You Had:
Any Tickets?: No Yes - How many?
Any Accidents?: No Yes - How many?
Any Major Traffic Violations?:
If for a motorcycle, do you have a motorcyle license: No Yes
Have you taken a motorcycle safety course?: No Yes
Vehicle #4:
Year:
Make:
Model:
For Motorcycle: CCs?
For Boat:
Horse PowerLengthMax SpeedPropulsionValue
TrailerYearLength
No
Yes
Coverage Desired: Liability Basic Full Coverage Package
Premier Full Coverage Package
Is there Coverage In Place Now?:
No Yes, fill in below:
CompanyAnnual PremiumType of CoverageExpiration Date
*Email Address:
*Privacy Statement: Bert's Mega Mall values the privacy of your personal information and at no time will share your email address with any other company or agency. Your email address will be used soley as a means of communication between Bert's Mega Mall and yourself. Your email address will not be shared or sold. Your information will be kept strictly confidential.
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Additional Comments:



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