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Second vehicle

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Who has insured you in the last 6 months?

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Do you own or rent your home?

Who is the insurance for?

What health insurance do you have now?

What’s your immigration status?

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Date of birth

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Street address City State ZIP code

Are you married?

Do you have children?

What’s your household income?

These amounts are

How much do you make? $ How much does your spouse make? $

Street address Phone

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