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1520 Siskiyou Blvd Medford, OR 97504
541-555-1234

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AUTO INSURANCE QUOTE

from Nelson & Shaw Insurance

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Personal Information

First Name ✶

Last Name ✶

Street Address ✶

City ✶

State ✶

ZIP ✶

Phone

Preferred Contact Method(s) ✶

Call

Text

Occupation

Vehicle Information

Vehicle

Year ✶

Make ✶

Model ✶

Vehicle Uses ✶

Pleasure

Work

School

Other

VIN

Owner

Name on Title

Purchase Date

Ownership

Lease

Loan

Own

Loan/Lease Company Name (if applicable)

Loan/Lease Company Address

Driver Information

Primary Driver

First & Last Name ✶

Date of Birth ✶

Annual Mileage ✶

Secondary Driver (if applicable)

First & Last Name

Date of Birth

Annual Mileage

Coverage Information

Current Insurance Company

Current Insurance Policy Expiration

Desired Coverage

Best coverage

Lowest deductible

Lowest rate

State minimum

Not Sure

Other (describe in comments)

Coverage Options

GAP / replacement cost

Medical payments

Rental reimbursements

Towing & roadside assistance

Additional Information

Comments

I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of Nelson & Shaw Insurance ✶

Subject

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1520 Siskiyou Blvd
Medford, OR 97504

541-555-1234

This sample insurance agency website was made using the Nelson Template on Webtricity.