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Have you had auto insurance in the past 30 days?

If so, for how long?

Has anyone on this policy had an at-fault
accident in the past 3 years?

If so, for how many?

Have you had two or more tickets in the past 3 years?

If so how many?


Almost there! Have you had a DUI conviction in the past 3 years?
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Coverage Type
Current Insurance Company
Desired Collision Coverage
Desired Comprehensive Coverage
Additional Driver
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