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Personal Information
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Alternate Phone Number
E-Mail Address *
Date of Birth *
/ /
Marital Status *
License (State, Number)
Vehicle Information
Year *
Make *
Model *
VIN #
Cylinders *
Coverage Options
Do you rent or own your home?
Do you currently have insurance?
Current Insurance Provider
If no, when did you last have insurance?
/ /
Comprehensive Deductible
Collision Deductible
Bodily Injury Liability *
Property Damage Liability *
Uninsured Motorist Bodily Injury
Uninsured Motorist Property Damage
Underinsured Motorist - Bodily Injury Limits
Underinsured Motorist - Property Damage Limits
Medical Pay / PIP
Towing
Rental
What percentage of your vehicles total use time is driven by you? *
How many miles will you drive your car annually? (Approximately)
Does this driver have any major violations (5yrs), accidents or minor violations (3yrs), comprehensive or collision claims (3yrs)? *
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A-Affordable Insurance
1635 S. Harvard, Tulsa, OK 74112

(918) 749-9500