; Schmitz Insurance_ LLC Automobile Insurance Information
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Schmitz Insurance_ LLC Automobile Insurance Information

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									                                                                                                    Print Form                  Submit by Email
Schmitz Insurance, LLC
Automobile Insurance Information                                                                     Current Date

 Name Address                                                                                                    Phone number



 Present auto insurance carrier and premium.                Homeowner (Y/N) and Company insured with.            Expiration date



                                                                                                    email
VEHICLE INFORMATION
     Year     Make and Model (on pickups include 4x4, ext cab, engine, equipment) and VIN#                     Body    Anti-       Air    cost new
                                                                                                               2d 4d   lock        Bag
                                                                                                               wagon   Brakes


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DRIVER INFORMATION (all drivers in household)
     Name                  M/S      Birthdate        Social Security #          Drivers License #                           Veh.     Good     Miles
                                                                                                                            No.      Stdnt    1-way

 1                         M


 2                         M


 3                         S


 4                         S



DRIVING RECORD
     Name                  Date                 Violation or Accident description and amount of damage

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COVERAGES
     Liability limits             Medical       Uninsured           Underinsured         Comprehensive   Collision     Towing        Rental limit
     Bodily Inj/Property          Payments      Motorist            Motorists            deductible      deductible    limit         per day/total

 1    250/500/100                 1000          250/500            250/500               100             500           NA            NA


 2    250/500/100                 1000          250/500            250/500               100             500           NA            NA


 3    250/500/100                 1000          250/500            250/500               100             500           NA            NA

         RETURN TO: PO BOX 98, FORESTVILLE, WI 54213                 OR CALL: 920-856-6211
         OR FAX TO: 815-301-9066                   e-mail Phil@SchmitzInsurance.com

								
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