ONLINE QUOTE

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You may request quotes for Business Insurance, Homeowner's Insurance and/or Auto Insurance using this form. Please fill in the blanks completely in each section for which you wish to receive a quote. When finished, press the "QUOTE" button at the bottom of the form.

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YOUR EMAIL ADDRESS (necessary for all quotes):

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BUSINESS

YOUR NAME:
YOUR COMPANY:
NATURE OF BUSINESS:
# OF EMPLOYEES:		# OF LOCATIONS:
POSTAL ADDRESS:
CITY, STATE, & ZIP:
PHONE #:		FAX #:

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HOMEOWNERS 

NAMED INSURED:
HOME PHONE:		WORK PHONE:
PROPERTY ADDRESS:
AMOUNT OF COVERAGE DESIRED:
BUILDING	DEDUCTIBLE	CONTENTS	LIABILITY
FRAME	BRICK VENEER	Foundation: Slab Elevated
TOTAL SQ. FT.		ROOF TYPE
YEAR BUILT*		NUMBER OF FAMILIES
*If over 20 years old, please list the year that the following was updated: Wiring Plumbing Roof Heating/A/C
PROTECTIVE DEVICES:
LOCAL BURGLAR?	Yes    No	LOCAL FIRE?	Yes    No
CENTRAL BURGLAR?	Yes    No	CENTRAL FIRE?	Yes    No
SMOKE DETECTOR?	Yes    No	FIRE EXTINGUISHER?	Yes    No
DEADBOLT LOCKS?	Yes    No	GATED COMMUNITY?	Yes    No
PRESENT INSURER		EXPIRATION
LIST DATE AND TYPE OF ANY RECENTLY CLAIMED LOSSES
OTHER PROPERTY OR BUSINESS OWNED.
ANIMALS: Yes   No If dog, what breeds?
POOL: Please check all that apply. Above Ground Below Ground Slide Diving Board Fenced

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AUTOMOBILE

NAMED OF INSURED:
HOME PHONE:		WORK OR CELL PHONE:
GARAGING ADDRESS:*
*If less than 3 years at this address, please include prior address:
	VEHICLE #1	VEHICLE #2	VEHICLE #3
YEAR:
MAKE/MODEL:
VIN#:
USE:	Select Pleasure Commute	Select Pleasure Commute	Select Pleasure Commute
BODILY INJURY:	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Select	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Select	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Select
UNINSURED MOTORIST:	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Decline Select	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Decline Select	$25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000 Decline Select
PROPERTY DAMAGE:	$10,000 $25,000 $50,000 $100,000 Select	$10,000 $25,000 $50,000 $100,000 Select	$10,000 $25,000 $50,000 $100,000 Select
MEDICAL PAYMENTS:	$1,000 $2,500 $5,000 $10,000 Select	$1,000 $2,500 $5,000 $10,000 Select	$1,000 $2,500 $5,000 $10,000 Select
COMPREHENSIVE DEDUCTIBLE:	$250 $500 $1000 Select	$250 $500 $1000 Select	$250 $500 $1000 Select
COLLISION DEDUCTIBLE:	$250 $500 $1000 Select	$250 $500 $1000 Select	$250 $500 $1000 Select
TOWING & LABOR:	$50 $75 Select	$50 $75 Select	$50 $75 Select
RENTAL REIMBURSEMENT:	$30 Per Day $40 Per Day $50 Per Day Select	$30 Per Day $40 Per Day $50 Per Day Select	$30 Per Day $40 Per Day $50 Per Day Select
DRIVER INFORMATION
NAME:
DATE OF BIRTH:
DRIVERS LICENSE:
SOCIAL SECURITY #:
GENDER:	Select Male Female	Select Male Female	Select Male Female
MARITAL STATUS:	Select Married Single	Select Married Single	Select Married Single
Tickets/Accidents:
Present Coverage?	Yes	No
Present Carrier?		Expiration:
Policy Number:
Do you Own or Rent your home?

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Copyright 2006, John W. Dussouy & Co. Inc
All Rights Reserved

DISCLAIMER NOTICE: The premiums quoted are estimates based on the information you have provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.