Archer A. Associates, Inc. - Insurance Agents and Brokers
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Insured’s Information
First Name *
Middle Initial
Last Name *
Address *
Street Address
Address Line 2
City State / Province / Region
Postal / Zip Code

Country

Phone Number *
### - ### - ####  
Email
Current Insurance
Do you currently have car insurance? *
Yes
No
Current Company
Renewal Date
MM / DD / YYYY  
Annual Premium
Have you been cancelled or non-renewed in the past 3 years?
Yes
No
Coverages
Bodily Injury Liability
Property Damage Liability
Medical Payments
Uninsured Motorist Liability
Uninsured Motorist Property
Underinsured Motorist Liability
Underinsured Motorist Property
Comprehensive Deductible
Collision Deductible
Rental Reimbursement
Yes
No
Towing & Labor
Yes
No
Licensed Drivers (1)
Name on License *
License State *
Gender
Male
Female
Marital Status
Relationship to Applicant
Occupation
Good Student?
Yes
No
Driver Training
Yes
No
Tickets and Accidents (last 5 years)

Licensed Drivers (2)
Name on License
License State
Gender
Male
Female
Marital Status
Relationship to Applicant
Occupation
Good Student?
Yes
No
Driver Training
Yes
No
Tickets and Accidents (last 5 years)

Vehicle(s) Information
Number
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive
Yes
No
Alarm System
Yes
No
Air Bags
Yes
No
Anti-Lock Brakes
Yes
No
Auto-Seatbelts
Yes
No
Vehicle(s) Information
...if more than one vehicle, proceed
Number
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive
Yes
No
Alarm System
Yes
No
Air Bags
Yes
No
Anti-Lock Brakes
Yes
No
Auto-Seatbelts
Yes
No
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