GARVER INSURANCE AGENCY
Dolores, CO 81323
(970) 565-2389
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Personal Information
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Name
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First
Last
DBA / LLC / CORP / PARTNERSHIP if applicable
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Date of birth
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Phone Number
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Email
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Mailing Address
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Line 1
Line 2
City
State
Zip Code
Country
Physical address if different from mailing address
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Line 1
Line 2
City
State
Zip Code
Country
Currently insured
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yes
no
If yes, Insurance Company name, expiration, and length of time insured
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Any claims in the last 5 years
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Yes
No
Requested effective date
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Building coverage limit if requested
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Liability limit
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100,000
300,000
500,000
1,000,000
other
Please list any specialty coverage you would like included in the quote
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FEIN #, years experience, and any other comments
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Expected annual earnings from business
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Vehicle Information if applicable
(please note that you may fax or email a copy of your current declaration page instead of filling this out.)
List business vehicle VIN# or Year, Make, and Model
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Coverage
Liability or Full Coverage
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Liability
Full coverage
Full coverage + glass
Full coverage + glass + roadside assistance
Full coverage + glass + roadside assistance + rental reimbursement
Deductible if full coverage is selected
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500
1000
other
Liability Limits Requested
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25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
500,000+
Is Vehicle Financed?
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YES
NO
If yes, name and address of lienholder for each vehicle (I can get this information after quoting if you would like)
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Please confirm all information provided above is correct.
All personal information provided is secure and confidential. You may be contacted to provide any additional information required.
Initial
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Date
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