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Primary use  
Annual Mileage  
Night parking  
Coverage desired  
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Do you have a valid drivers License?   Yes No
Add an additional driver?   Yes No
Add an additional auto?   Yes No
Have you filed recent claims?   Yes No
Have you had insurance in the past 30 days?   Yes No
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Date of birth  
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Years Lived there  
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Age first Licensed  
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First name:     Last name:  
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