TE ALLAN INC
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INSURANCE QUOTE FORM
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TE ALLAN INC
Home
About Us
Staff
Companies we work with
INSURANCE QUOTE FORM
Contact Us
Discount Travel Adventures Quote
Home
INSURANCE QUOTE FORM
INSURANCE QUOTE FORM
First Name
*
Last Name
*
E-mail
*
Phone Number
*
Physical Address:
*
Mailing Address: (If different than Physical Address)
Copy of Currrent Insurance Dec Pages
1.) Primary Household Drivers Full Name; Date of Birth; Drivers License # ; Married or Single
*
2.) 2nd Household Drivers Full Name; Date of Birth; Drivers License # ; Married or Single
3.) 3rd Household Drivers Full Name; Date of Birth; Drivers License # ; Married or Single
4.) 4th Household Drivers Full Name; Date of Birth; Drivers License # ; Married or Single
Tickets or accidents in the last three years (If so please list them all and who got them)
*
All Vehicles Year; Make; Model; VIN number (17 digits);
*
I have a loan on a vehicle (#) and its with...
Coverage Type I am looking for...
*
Full Coverage
Basic Liability (State Limits)
Drivers License (Coverage just on my license)
Full Coverage Comprehensive deductibles...
$100
$250
$500
$1000
Full Coverage Collision deductibles...
$100
$250
$500
$1000
Towing Coverage
Yes
NO
Rental Coverage
Yes
NO
Rental Coverage Amount
$20 a day
$40 a day
$60 a day
Do you currently own or rent a home?
Yes Own
Yes Rent
No
Would you like me to quote your home or rental insurance to see if I can get you a package rate?
Yes
No
SUBMIT QUOTE REQUEST
Thank you for submitting your request.
509-697-5383
Allaninsurance@fairpoint.net
312 South 1st Street, Selah, WA, USA