MARKETING SUPPLY ORDER FORM PLEASE FAX REQUEST TO 904-396-5920

							                                                               www.us-insurance.com



                       MARKETING SUPPLY ORDER FORM
                     PLEASE FAX REQUEST TO 904-396-5920



                             “Protect Your Pleasure”
                               Motorcycle Poster “      Quantity ________________
                                    17” x 24”



                             “Protect Your Pleasure”
                                  Boat Poster “         Quantity ________________
                                    17” x 24”


                                                        Pre-packaged in bundles of
                                                                   25
                             Motorcycle, Watercraft
                                         &               Motorcycle Packs _____
                             Travel Trailer Insurance
                              Marketing Brochures        Watercraft Packs _____

                                                         Travel Trailer Packs _____


AGENCY / COMPANY                                                PRODUCER CODE



ATTENTION



SHIP TO ADDRESS



CITY / STATE / ZIP



PHONE NUMBER                                  EMAIL ADDRESS




  P.O. Box 47000i Jacksonville, FL 32247-7000i800-874-1738iFax 904-396-5920