Westan Insurance Group, Inc.

July 28, 2004

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Customer information
Customer name:
Address:
Telephone number:
E-mail:
Current insurer:
Expiration:

Driver information
Driver 1
Name:
Date of birth:
License:
SSN:
Driver 2
Name:
Date of birth:
License:
SSN:
Driver 3
Name:
Date of birth:
License:
SSN:
Driver 4
Name:
Date of birth:
License:
SSN:
Driver 5
Name:
Date of birth:
License:
SSN:

Vehicle information
Vehicle 1
Year:
Make:
Model:
VIN#:
Vehicle 2
Year:
Make:
Model:
VIN#:
Vehicle 3
Year:
Make:
Model:
VIN#:
Vehicle 4
Year:
Make:
Model:
VIN#:

Coverages:
Cars:
Liability limits:
Medical payments:
Other than collision:
Collision:
Uninsured motorist:
Towing:
Rental:
Any other information or coverages needed:


Do you own your home or condominium?
Yes No
If Yes, what company currently writes your Homeowners Insurance?