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In order to find the most affordable health insurance coverage possible, it is important to check rates and plans from multiple carriers. Since each health insurance carrier has different underwriting policies, rates can vary quite a bit from one company to the next.

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Name
Address
City
State  Zip 
Work 
Phone
Home 
Phone
E-mail
Present Auto Insurance Company
Date Auto Insurance Expires
Do you own a home? Yes  No
How long at your present address?

 Year  VIN  Make  Model 2dr/4dr Miles to Work (one way) Annual Mileage

Driver Name
Date of Birth
Sex
Marital Status
Occupation
Number of Tickets in Last 3 Years
Number of Accidents in Last 3 Years
% of Use  
Car #1
Car #2
Car #3
Car #4
Car #5

LIABILITY LIMIT FOR ALL CARS
Bodily Injury Property Damage
Single Limit 
  choose one
25,000/50,000 25,000
60,000
50,000/100,000 50,000
100,000
100,000/300,000 100,000
300,000
250,000/500,000 500,000
500,000
Choose either Bodily Injury & Property Damage OR Single Limit

Car # Deductible Comprehensive Deductible Collision Tow Loss of Use
1 100 250 500 250 500 1000 Yes Yes
2 100 250 500 250 500 1000 Yes Yes
3 100 250 500 250 500 1000 Yes Yes
4 100 250 500 250 500 1000 Yes Yes
5 100 250 500 250 500 1000 Yes Yes


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