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(740) 927-1469
30 S Township Rd Ste B
Pataskala, OH 43062
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Primary Vehicle:
Year
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Make
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Model
*
VIN
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Drive to Work/School?
*
Yes
No
Work/School Distance
*
Less than 5 Miles
5 Miles
10 Miles
15 MIles
20 Miles
30 Miles
Over 30 Miles
N/A
Annual Mileage
*
5,000
7,500
10,000
12,500
15,000
20,000
25,000
30,000
40,000
50,000+
Collision Deductible
*
No Coverage
$100
$250
$500
$1000
Other
Comprehensive Deduct
*
No Coverage
$100
$250
$500
$1000
Other
Who Drives This Vehicle?
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Vehicle #3 (if necessary)
Year (V3)
*
Make (V3)
*
Model (V3)
*
VIN
*
Used for Commute? (V3)
*
Yes
No
Work/School Distance (V3)
*
Less than 5 Miles
5 Miles
10 Miles
15 MIles
20 Miles
30 Miles
Over 30 Miles
N/A
Annual Mileage (V3)
*
5,000
7,500
10,000
12,500
15,000
20,000
25,000
30,000
40,000
50,000+
Collision Deduct. (V3)
*
$100
$250
$500
$1000
No Coverage
Comp Deduct. (V3)
*
$100
$250
$500
$1000
No Coverage
Who Drives This Vehicle?
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Vehicle #2 (if necessary)
Year (V2)
*
Make (V2)
*
Model (V2)
*
VIN
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Used for Commute? (V2)
*
Yes
No
Work/School Distance (V2)
*
Less than 5 Miles
5 Miles
10 Miles
15 MIles
20 Miles
30 Miles
Over 30 Miles
N/A
Annual Mileage (V2)
*
5,000
7,500
10,000
12,500
15,000
20,000
25,000
30,000
40,000
50,000+
Collision Deduct. (V2)
*
$100
$250
$500
$1000
No Coverage
Comp Deduct. (V2)
*
$100
$250
$500
$1000
No Coverage
Who Drives This Vehicle?
*
Vehicle #4 (if necessary)
Year (V4)
*
Make (V4)
*
Model (V4)
*
VIN
*
Used for Commute? (V4)
*
Yes
No
Work/School Distance (V4)
*
Less than 5 Miles
5 Miles
10 Miles
15 MIles
20 Miles
30 Miles
Over 30 Miles
N/A
Annual Mileage (V4)
*
5,000
7,500
10,000
12,500
15,000
20,000
25,000
30,000
40,000
50,000+
Collision Deduct. (V4)
*
$100
$250
$500
$1000
No Coverage
Comp Deduct. (V4)
*
$100
$250
$500
$1000
No Coverage
Who Drives This Vehicle?
*
Additional Coverages
Choose Any
*
None
Towing
Rental Car
Loan/Lease Gap Coverage
$0 Glass Deductible
Driver Information
Primary Driver Name
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Gender
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Female
n/a
Birthdate
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Married?
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Yes
No
Driver's License #
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Driver 3 Name (if necessary)
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Gender (D3)
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Male
Female
n/a
Married? (D3)
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Yes
No
Birthdate (D3)
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Driver's License #
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Driver 2 Name (if necessary)
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Gender (D2)
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Male
Female
n/a
Birthdate (D2)
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Married? (D2)
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Yes
No
Driver's License #
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Driver 4 (if necessary)
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Gender (D4)
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Male
Female
n/a
Birthdate (D4)
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Married? (D4)
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Yes
No
Driver's License #
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Current or Prior Insurance Company
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Continuous Coverage
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Select One
Not Currently Insured
Under 6 Months
6 Months
12 Months
1-3 Years
3-5 Years
5+
Claims in 3 Years
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None
1
2
3
4+
Policy Expires In
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Select One
Not Sure
A few days
2 weeks
1-3 months
3-6 months
6+ months
Tickets in 3 Years
*
None
1
2
3
4
5
6+
Coverage Desired
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Select One
State Minimum
50/100/50
100/300/100
250/500/250
Other
Name
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Last
Address
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Home
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