Bucki Insurance Center

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Company:

 

Your Name:

 

Address:

 

City: State: Zip Code:

 

Home Phone # Home Fax #

 

Work Phone # Work Fax #

  Please list each drivers First and Last name, and each driver's Birth date.
Driver #1 (First Last)   Birth Date (MM/DD/YY)

Driver #2 (First Last)   Birth Date (MM/DD/YY)

Driver #3 (First Last)   Birth Date (MM/DD/YY)

 

 List the names and birth dates of all others in the household who are of driving age.

Dependents None 1 2 3 4 5 6 7 8 9 10 Other

List all Tickets and/or Accidents within the past five years of anyone in your household

 

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INFORMATION ABOUT THE CARS TO BE INSURED

Car #1    Year 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 Prior to 85      Make GMC Acura Buick Chevrolet Chrysler Dodge Ford Honda Lexas Mazda Olds Pontiac Suzuki Toyota Other

 

Type/VIN    Driver Number (see above) Driver #1 Driver #2 Driver #3

 

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Car #2    Year None 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 85      Make None Acura Buick Chevrolet Chrysler Dodge Ford GMC Honda Lexas Mazda Olds Pontiac Suzuki Toyota Other

 

Type/VIN    Driver Number (see above) None Driver #1 Driver #2 Driver #3

 

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Car #3    Year None 99 98 97 96 95 94 93 92 91 90 89 88 87 86 85 85      Make None Acura Buick Chevrolet Chrysler Dodge Ford GMC Honda Lexas Mazda Olds Pontiac Suzuki Toyota Other

Type/VIN    Driver Number (see above) None Driver #1 Driver #2 Driver #3

 

VAN CONVERSION/CLASSIC CAR

 

Van Conversion Value $             Corvette/Classic Car Value $

 

If this is a new purchase in the current year and/or is not in the manual,
What is the Approximate Value New $

 

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  HEALTH INSURANCE

 

Do you have health insurance? Yes No       If not, do you want health insurance? No Yes

Name of current Health Co or Employer Name?

 

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CHECK THE TYPES OF INSURANCE YOU WANT FOR EACH VEHICLE

Car #1

 

BI   $500,000/$500,000 $300,000/$300,000 $100,000/$300,000       PD   $100,000 $300,000 $500,000       COMP   $50 Deductible $100 Deductible

COLL Deductible $100 $250 $500 Other       R/S None $25 $50 $75       Do you rent or own? (home) Rent Own

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Car #2

 

BI   $500,000/$500,000 $300,000/$300,000 $100,000/$300,000       PD   $100,000 $300,000 $500,000       COMP   $50 Deductible $100 Deductible

COLL Deductible $100 $250 $500 Other       R/S None $25 $50 $75       Do you rent or own? (home) Rent Own

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Car #3

 

BI   $500,000/$500,000 $300,000/$300,000 $100,000/$300,000       PD   $100,000 $300,000 $500,000       COMP   $50 Deductible $100 Deductible

COLL Deductible $100 $250 $500 Other       R/S None $25 $50 $75       Do you rent or own? (home) Rent Own

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