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Insurance Affiliates Agency 

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Contact Information

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DATE:
First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
DATE OF BIRTH:
HOME OWNER YES/NO:
                           COMMERCIAL/TRUCKING
BUSINESS NAME:
TYPE OF BUSINESS SOLE PROP/COPR,LLC/PARTNERSHIP:
D.B.A.:
CDL #
YEAR CDL ISSUED:
SR-22 IF YES CASE #
VIN #:
ONE WAY RADIUS (MILES):
VALUE OF VEHICLE:
PERMANETLY ATTACHED EQUIPMENT:
TOTAL STATED VALUE:
Comments:

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