Insurance Quote Form(s)

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Automobile and Life Insurance Quote Form

Insurance Quote Information

Please Copy, Paste and Fill out this quote application, Fax or email to the following.

Fax to: (910) 423-8549 or Email to: MNone5814@aol.com

Name of Insured _____________________________ Tele: _________________________

Address: ____________________________________ Marital Status ________________

City _________________________ State: __________________ Zip Code; ______________

Age: __ Date of Birth ________ Gender: _________ License No. _______________ State ___

Circle here to mail quote or Telephone Number to Fax Quote; _________________

Type of Insurance (Circle One):   LIFE    AUTO     HOMEOWNERS

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Fill out for Automobile Insurance

Auto 1 Make _________ Model _________ Year:_______ VIN #: _____________________

Auto 2 Make _________ Model _________ Year:_______ VIN #: _____________________

Auto 3 Make _________ Model _________ Year:_______ VIN #: _____________________

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Additional Insured Name ______________________________ Relation: ________________

Age: __ Date of Birth ________ Gender: _________ License No. _______________ State ___

Additional Insured Name ______________________________ Relation: ________________

Age: __ Date of Birth ________ Gender: _________ License No. _______________ State ___

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Type of Coverage (Circle ):   Liability only    or    Collision Collision & Comprehensive

Deductible (Circle One): 0   $250   $500   $1000   $2000

Med Pay Option (Circle One) $500   $1000   $1500   $2000

Towing Coverage: Yes / No Lien Holder/Address: _________________________________

Car Rental: Auto One (Yes / No ) Auto Two (Yes / No ) Auto Three (Yes / No )

 

Home Insurance Quote Information

Please Copy and Fill out this quote application, Fax or email to the following.

Fax to: (910) 423-8549 or Email to:  MNone5814@aol.com

 Name of Insured _____________________________ Tele: _________________________

Address: ____________________________________ Marital Status ________________

City _________________________ State: __________________ Zip Code; ______________

Age: __ Date of Birth ________ Gender: _________

Circle here to mail quote    or Telephone Number to Fax Quote; _________________

______________________________________________________________________________

Fill out for Home Insurance

Address of Property: _______________________ City: __________________ State ______

Estimated Value of Property: _________________ Insured Amount __________________

Is the property owner occupied? Yes / No Is the property tenant occupied? Yes / No

Do you currently have coverage? Yes / No

Have you any claim in the last 5 years? Yes / No If you answered yes, Please give the date of the claim, the name of carrier, and the amount of claim in the spaces below.

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Do you run a business from your home? Yes / No If yes, what type: __________________

Square Feet of Home: __________________ Type of Construction: __________________

Year Built: _________________________ Distance from Fire Station ___________________

Any upgrade to plumbing, electrical, or roof? Explain: _________________________________

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Mortgage Holder Name and Address: _______________________________________________

Date Insurance to start: _________________

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Life Insurance Quote Information

Please Copy and Fill out this quote application, Fax or email to the following.

Fax to: (910) 868-3337 or Email to: MNone5814@aol.com

 

Name of Insured _____________________________ Tele: _________________________

Address: ____________________________________ Marital Status ________________

City _________________________ State: __________________ Zip Code; ______________

Age: __ Date of Birth ________ Gender: _________

Amount of coverage: ____________________

Type of Life insurance (Circle all that apply): Term Universal Whole life Annuity

Have you been hospitalized in the last 10 years? Yes / No

Do you smoke or use tobacco? Yes / No

Do you have any or being treated for a serious illness? Yes / No (diabetes, cancer, stroke, etc)

Do you want any additional insurance riders. If so, circle each one you want.

Additional Insured rider Child riders Return of premiums rider accidental death rider

Policy Owner: _________________________

Beneficiary(s) ____________________ Address______________________ Relation ________

Beneficiary(s) ____________________ Address______________________ Relation ________

Beneficiary(s) ____________________ Address______________________ Relation ________

Place your children name(s), sex, date of birth, age For coverage

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