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Shelton Insurance
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| Name (required) | |
| E-mail (required) | |
| Telephone (required) | |
| Address (required) | |
| City (required) | |
| State (required) | |
| Zip (required) | |
About your vehicles:
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Year, Make, and Model or VIN # (VIN # is preferred) |
Garaging zip code: (Required) |
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| Vehicle #1: |
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| Vehicle #2: |
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| Vehicle #3: |
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| Vehicle #4: |
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Coverage Desired:
| Bodily Injury | ||||
| Property Damage | ||||
| Uninsured Motorist | ||||
| Underinsured Motorist | ||||
| Medical Coverage | ||||
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Vehicle 1 |
Vehicle 2 |
Vehicle 3 |
Vehicle 4 |
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| Comprehensive | ||||
| Collision | ||||
| Rental | ||||
| Towing | ||||
About the drivers:
| Gender | Married | D.O.B | Drivers License # | |||
| Primary |
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| Spouse | ||||||
| Driver 3 | ||||||
| Driver 4 | ||||||
About driving distance:
| Vehicle | Driver |
Miles to work |
Miles to school |
| Vehicle #1 | |||
| Vehicle #2 | |||
| Vehicle #3 | |||
| Vehicle #4 |
About driving records:
(# Tickets and Accidents last 3 years; DUI- 5 yrs)
| Driver | Tickets | Accidents | DUI |
| Requested Effective Dt: | |
| Current Auto Insurer: | |
| Payment Frequency: | |
| Next Payment Due: |
Additional Comments: