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Which of our groups are you with? ---William LumberAstor ServicesRhinebeck Area ChamberNorthern Dutchess ParamedicsHealth-Quest Name Address Telephone Email Driver 1 Name Date of Birth Drivers License Number Social Security Number Do you have any of the following? ---AccidentsTicketsClaimsAll of the Above If Yes, please give a brief explanation What is your highest level of Education? ---High SchoolAssociates DegreeBachelors DegreeMasters DegreePhD Driver 2 Name Date of Birth Drivers License Number Social Security Number Do you have any of the following? ---AccidentsTicketsClaimsAll of the Above If Yes, please give a brief explanation What is your highest level of Education? ---High SchoolAssociates DegreeBachelors DegreeMasters DegreePhD Are their any other drivers or regular operators of your vehicles? yesno If Yes, Please provide some details
Vehicle Information Section Year Make Model Year Make Model Year Make Model Coverage Section What are your current liability limits? ---25,000/50,00050,000/100,000100,000/300,000250,000/500,00050,000100,000300,000500,0001,000,000 What are your current Uninsured/Underinsured limits? ---25,000/50,00050,000/100,000100,000/300,000250,000/500,00050,000100,000300,000500,0001,000,000 What is your Aggregate Personal Injury Protection? ---50,000100,000125,000150,000175,000 Is there Comprehensive and Collision Coverage on your vehicles? ---None of themSome of themAll of them Comprehensive and Collision Deductibles ---0501002505001,000Various How did you learn about the program? ---NewsletterE-mailPayroll StufferOnsite visitBenefits fair Please use this link to upload a copy of your current Declarations page, by doing this you will speed up the process and increase accuracy. File types limited to gif, tif, jpg and pdf