GARVER INSURANCE AGENCY
Dolores, CO 81323
(970) 565-2389
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HOME/AUTO INSURANCE QUOTE FORM
Personal Information
(if home quote only, skip to bottom of form after completing personal information)
*
Indicates required field
Name
*
First
Last
Date of birth
*
Married?
*
yes
no
Please list spouse/additional drivers and their date of birth as well as drivers licenses here
*
Phone Number
*
Email
*
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Currently insured
*
yes
no
If yes, Insurance Company name, expiration, and length of time insured
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Any violations, accidents, or claims in the last 5 years
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Yes
No
SR-22/State Filing needed
*
yes
no
Own home?
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Own home
Own mobile home
Rent
Other
Physical address ((location to be insured) if different from mailing address
*
Line 1
Line 2
City
State
Zip Code
Country
Vehicle Information
(please note that you may fax or email a copy of your current declaration page instead of filling this section out.)
Drivers License #
*
VIN#, Year, Make, and Model
*
Additional vehicles VIN#, Year, Make, and Model
*
Coverage
Liability or Full Coverage
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Liability
Full coverage
Full coverage + glass
Full coverage + glass + roadside assistance
Full coverage + glass + roadside assistance + rental reimbursement
Deductible if full coverage is selected
*
500
1000
other
Liability Limits Requested
*
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
500,000+
Is Vehicle Financed?
*
YES
NO
If yes, name and address of lienholder for each vehicle (I can get this information after quoting if you would like)
*
Home Insurance or Rental Insurance Information (if quote requested)
(Note, you may also fax or email me a current declaration page instead of filling out this portion.)
Policy selection
*
none
home
mobile home
rental
Foundation type
*
Concrete slab
Crawl Space
Basement
Blocked leveled and skirted
Specialty policies qualify for multi-policy discounts.
Dwelling requested amount
*
Liability limits
*
25,000
50,000
100,000
300,000
500,000
1,000,000+
If currently insured, current insurance company, years insured, and expiration
*
This field is for discount purposes.
Requested effective date
*
Any claims in the last 5 years
*
yes
no
Please confirm all information provided above is complete and correct.
All personal information provided is secure and confidential. You may be contacted to provide any additional information required.
Initial
*
Date
*
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