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I would like insurance information regarding:

Auto & Truck
Boat
Jet Ski
Motorcycle
Camper/RV
Snowmobile
Antique Auto

Name:
 
Address: 

City:  
State:  Zip: 
Phone: 

Fax:     

Email:  

Best Method of Contact:


Driver Information: 

Name of Driver 1:

Age of Driver 1:
Drivers Training?:
Number of Citations:
Number of Chargeable Accidents:


Name of Driver 2:

Age of Driver 2:
Drivers Training?:
Number of Citations:
Number of Chargeable Accidents:


Name of Driver 3:

Age of Driver 3:
Drivers Training?:
Number of Citations:
Number of Chargeable Accidents:


Name of Driver 4:

Age of Driver 4:
Drivers Training?:
Number of Citations:
Number of Chargeable Accidents:


Vehicle Information: 

Vehicle 1:

 

Year/Make/Model:

Automatic Seat Belt:     Air Bag:         4Wheel Anti-Lock Brakes:
Comprehensive Coverage Deductible:   Collision Coverage Deductible: Tort Options:

Check here for Rental Car Coverage:
Check here for Towing Coverage:

Vehicle used for Work or Pleasure


Vehicle Information: 

Vehicle 2:

 

Year/Make/Model:

Automatic Seat Belt:     Air Bag: 
4Wheel Anti-Lock Brakes:
Comprehensive Coverage Deductible:
Collision Coverage Deductible: Tort Options:
Check here for Rental Car Coverage:
Check here for Towing Coverage:

Vehicle used for Work or Pleasure


Vehicle Information: 

Vehicle 3:

 

Year/Make/Model:

Automatic Seat Belt:     Air Bag:         4Wheel Anti-Lock Brakes:
Comprehensive Coverage Deductible:   Collision Coverage Deductible: Tort Options:

Check here for Rental Car Coverage:         
Check here for Towing Coverage:

Vehicle used for Work or Pleasure


Vehicle Information: 

Vehicle 4:

 

Year/Make/Model:

Automatic Seat Belt:     Air Bag:         4Wheel Anti-Lock Brakes:
Comprehensive Coverage Deductible:   Collision Coverage Deductible: Tort Options:

Check here for Rental Car Coverage:
Check here for Towing Coverage:

Vehicle used for Work or Pleasure


 

What concerns do you have with your current program?

 

How can we earn your business? 

 

Is there anything else you would like us to know about your current situation? 

 

If you are you part of an association or employer sponsored group, please list it here:

If not, how did you find Daly Merritt, Inc.?

 

 


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© Copyright 2000 Daly Merritt, Inc.
2121 Biddle Avenue, Suite 200
Wyandotte, Michigan 48192
Direct: 734-283-1400 Fax: 734-283-1197