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	•  Auto Insurance Quote   •  Homeowners Insurance Quote   •  Motorcycle Insurance Quote   •  Boat / Watercraft Quote   •  RV / Motorhome Quote   •  Flood Insurance Quote   •  Renters Insurance Quote Florida Insurance Agency 10269 W Sample Rd. Coral Springs,  Florida 33065 Phone:  954-825-0333 Email:  info@floridaagency.com 12008 South Shore Blvd. Ste. 208 Wellington, Florida 33414 Phone  561-798-3722 Email: carolyn@floridaagency.com	Motorcycle, ATV Insurance Quote First & Last Name:   Street Address:   City, State & Zip:   E-Mail Address:   Telephone:   Fax:   # of years @ Current Address:   Do You Own a Home?:   Yes No Vehicle Information (List all cars you or family own/lease) Vehicle 1:   Year Make/Model Vin # Yearly Mileage Usage Alarm Select.. Pleasure Work over 3 mi. Work less 3 mi. Business Yes No Vehicle 2:   Year Make/Model Vin # Yearly Mileage Usage Alarm Select.. Pleasure Work over 3 mi. Work less 3 mi. Business Yes No Any Custom equipment of vehicles? (if YES, give their value):   Coverage Information Liability limits for bodily injury & property damage:   Select... $10,000/$20,000/$10,000 $25,000/$50,000/$25,000 $50,000/$100,000/$25,000 $100,000/$300,000/$50,000 $250,000/$500,000/$100,000 $100,000 combined limit $300,000 combined limit $500,000 combined limit Deductibles Comp. & Collision Towing coverage Rental Reimb. Vehicle 1:   Select.. $100/$100 $100/$250 $100/$500 $100/$1,000 $250/$100 $250/$250 $250/$500 $250/$1,000 $500/$100 $500/$250 $500/$500 $500/$1,000 $1,000/$100 $1,000/$250 $1,000/$500 $1,000/$1,000 Yes No Yes No Vehicle 2:   N/A $100/$100 $100/$250 $100/$500 $100/$1,000 $250/$100 $250/$250 $250/$500 $250/$1,000 $500/$100 $500/$250 $500/$500 $500/$1,000 $1,000/$100 $1,000/$250 $1,000/$500 $1,000/$1,000 N/A Yes No N/A Yes No Current Insurance Information Insurance Company Name:   Policy Exp. Date:   Premium Amt:   Term:   How long with current?   Driver 1 Name:   Sex:   Male Female DL # (optional):   Marital Status:   Married Single Date of birth:   Driver's Education?:   Yes No S.S.# (optional):   Defensive Driving:   Yes No Years Licensed:   Good Student:   Yes No Occupation:   SR 22 filing?:   No Yes Driver 2 Name:   Sex:   Male Female DL # (optional):   Marital Status:   Married Single Date of birth:   Driver's Education?:   Yes No S.S.# (optional):   Defensive Driving:   Yes No Years Licensed:   Good Student:   Yes No Occupation:   SR 22 filing?:   No Yes Accidents / Violations in the last 5 years? Date Driver Violation Cost ($) Select.. Speed under 20 mph Speed over 20 mph At fault accident Non At fault accident DUI Reckless driving Minor not listed Major not listed Select.. Speed under 20 mph Speed over 20 mph At fault accident Non At fault accident DUI Reckless driving Minor not listed Major not listed Select.. Speed under 20 mph Speed over 20 mph At fault accident Non At fault accident DUI Reckless driving Minor not listed Major not listed Select.. Speed under 20 mph Speed over 20 mph At fault accident Non At fault accident DUI Reckless driving Minor not listed Major not listed List any DUI convictions, license suspensions or revocations:   Any additional comments or information that might be helpful in your quote: Note: By submitting this form you understand that no coverage is bound unitl you receive written notice. Image Validation: Please enter the characters in the image to the right. All letters are lowercase. Characters:
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