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Russ Towers Towers Lemos Insurance Agency
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Name of Business:
Corp or LLC?: Yes No
First & Last Name:
Street Address:
City, State, Zip:
Email Address:
Telephone:
   
Current Insurance Company (if any):
Current Liability Limits:
Expiration Date of Current Policy:
   
Liability Desired:
   
Number of Vehicles:
Vehicle 1  
Year: Make: Vin:
GVW: Cost New:
Collision: Yes No
Comprehensive: Yes No
Vehicle 2
Year: Make: Vin:
GVW: Cost New:
Collision: Yes No
Comprehensive: Yes No
Vehicle 3
Year: Make: Vin:
GVW: Cost New:
Collision: Yes No
Comprehensive: Yes No
Vehicle 4
Year: Make: Vin:
GVW: Cost New:
Collision: Yes No
Comprehensive: Yes No
 
Number of Drivers:
Driver 1
Name:  
Date of Birth:
Sex: Male Female  
Married: Yes No  
License #:
Accidents/violations/claims past three years?: Yes No
If Yes, what and when and who was the driver:
Driver 2  
Name:  
Date of Birth:
Sex: Male Female  
Married: Yes No  
License #:
Accidents/violations/claims past three years?: Yes No
If Yes, what and when and who was the driver:
Driver 3  
Name:  
Date of Birth:
Sex: Male Female  
Married: Yes No  
License #:
Accidents/violations/claims past three years?: Yes No
If Yes, what and when and who was the driver:
Driver 4  
Name:  
Date of Birth:
Sex: Male Female  
Married: Yes No  
License #:
Accidents/violations/claims past three years?: Yes No
If Yes, what and when and who was the driver:
 
Additional Comments:  
   
 

 

 

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