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General Information:
Owner's First Name:*
Middle:
Last:*
Address:*
City:*
State:*
Zip:*
Date of Birth:*		(mm/dd/yyyy)
Preferred Phone #
Secondary Phone #:
Email:*
Do you currently have life insurance?		Yes No
If yes, how much?
Do you currently have health insurance?		Yes No
Do you currently have a home-based business or do you currently own a business?		Yes No
Answer the following questions to maximize your discounts for auto insurance:
How many years have you lived at your current residence?
How many years have you been with your current carrier?
Have you taken a certified driver training course and do you have a certificate?		Yes No
Driver training information:		In Control Advanced Driver Training Skid School
Does your student driver maintain a B average or better?		Yes No
Do you have any children in college and where do they go to school?
Do you drive a hybrid vehicle?		Yes No
Are you a member of one of the following motor clubs?
If AAA Membership, how long have you been a member?
Do you have a Savings Bank Life Insurance (SBLI) Policy?		Yes No
Would you consider paying electronically (EFT) to save 8% on your auto premium?		Yes No
Are you a member of WBUR/NPR Radio?		Yes No
Please check the following features that are most important to you:
Accident Forgiveness		Identity Theft Resolution
Diminishing Deductible		OEM Parts Coverage
Lease/Loan Gap Coverage		New Vehicle Replacement Cost