Advantage Insurance Corp.
"Our Service is Your Advantage"
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Contact Details
Name
Street Address
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Date Auto Insurance Expires?
Vehicle #1
Make/Model
VIN #
Discounts
Usage
Driver Car #1
Status
Driver Car #2
Driver Car #3
Bodily Injury Liability
1000 Ded Coll.
100 Ded Comp.
Car #1
Car #3
Car #2
1000 Ded Coll.
Comprehensive Deducitble
100 Ded Comp..
250 Ded Comp.
Collision Deducitble
500 Ded Comp.
500 Ded Comp.
500 Ded Comp.
Car #1
Car #2
Car #3
Towing
Loss of Use
Other Coverages
1000 Ded Coll.
100 Ded Comp.
250 Ded Coll.
250 Ded Coll.
250 Ded Coll.
500 Ded Coll.
500 Ded Coll.
500 Ded Coll.
250 Ded Comp..
250 Ded Comp
Special Equipment
Property Damage
Have you had insurance for at least 6 months?
Do you currently have Home or Renters Insurance?
Last 3 yrs.-Accidents
Vehicle #2
Vehicle #3
COVERAGES FOR ALL VEHILCES
Year
(Any after factory items such as daytime running Lights, radio equipment, oversized tire and wheels, roll bars, deer catchers. If so, please describe below for which car)
DRIVER INFORMATION
Discounts
Birthday: Month
Day
year
SR22
(state below in box which driver)
Last 3 yrs.-Tickets
Uninsured Motorist Property Damage
Uninsured Motorist Bodily Injury Liab.
Disclaimer: The information and descriptions contained on this site are intended for general informational purposes and do not constitute an insurance contract. For complete details of coverage, conditions, terms, and exclusions, please refer to your insurance policy.
  You should receive a reponse within 48 hours or the next business day.
Type "'N/A" in the Make/Model and VIN # Boxes for vehicles #2 and #3 if you only have one vehicle.
Please List specific tickets and accidents in the box below.
(Form will not submit, unless all lines in Red are completed. Just write "N/A" if doesn't apply or if you do not know the answer.)
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