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TroyerInsurance.com insurance expert Brian Taylor
Hello, I'm Brian Troyer, 2nd
generation owner of Troyer
Insurance. I started in our
family agency in 1994. It is
my goal to provide you with
outstanding customer service.
I welcome you to give me a call,
and I will make you another
satisfied member of our
insurance family.

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Your Personal Data

Your Name (First & Last):
Street Address:
City:
State:
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
(Stick Built)
Yes No
 
Mobile Homeowner?
(Single or Doublewide)
Yes No
Total # of Members
in Household:
(age 14 and over)
 
Do you have Medical Insurance?
(If YES, list company below)
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Are Your Currently Insured?
(If YES, list answers to questions below)
 Yes No
Carrier Name:
 Bodily Injury Limits:
# Months of continuous coverge:
 Renewal Date if Known:

 

DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): Male
Female 		Relationship to Insured:
Please list all "Tickets", "Accidents" (At fault and/or Not-at-fault), and "Comprehensive" claims in the last 3 years below.
Be specific as to the TYPE of TICKETS, and approximate dates:
Occupation & Name of Employer: Daily commute
in ONE WAY miles:

 

DRIVER INFORMATION #2
Name: Birthdate:
Sex (M/F): Male
Female 		Relationship to Insured:
Please list all "Tickets", "Accidents" (At fault and/or Not-at-fault), and "Comprehensive" claims in the last 3 years below.
Be specific as to the TYPE of TICKETS, and approximate dates:
Occupation & Name of Employer: Daily commute
in ONE WAY miles:

ADDITIONAL DRIVER INFORMATION
If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

YOU'RE ALMOST DONE...SIMPLY COMPLETE VEHICLE INFORMATION!

VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make:
Model: VIN# (if known, for rating accuracy):
Vehicle used in business? Yes No If YES, explain business usage:
VEHICLE #1 COVERAGES:
Select Coverages

 
DEDUCTIBLES BELOW DO NOT APPLY TO PL/PD ONLY COVERAGE

Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?		 YES NO
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make:
Model: VIN# (if known, for rating accuracy):
Vehicle used in business? Yes No If YES, explain business usage:
VEHICLE #2 COVERAGES:
Select Coverages

 
DEDUCTIBLES BELOW DO NOT APPLY TO PL/PD ONLY COVERAGE>

Select Comprehensive Deductible:
 
Select Collision Deductible:
 
Rental Car &
Towing Coverage?		 YES NO
 
ADDITIONAL VEHICLE INFORMATION
If More than 2 Vehicles, list Additional Vehicles Year, Make, Model, Vin# and Coverages here:

Additional Comments or Remarks Here:

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Troyer insurance agency
 
Thank you for visiting the insurance web site of Troyer Insurance Agency, Inc.
E-Mail: troyerinsurance@aol.com   |   More About our Agency's Services
1015 N. Nottawa Street   Sturgis, MI 49091   (Click for Map/Directions)    |    Phone: 269-651-9060
Toll Free Phone: 800-617-9060    |    Fax: 269-651-5253   |    © 2007 Insurance-Web-Sales
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