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strict warning: Non-static method view::load() should not be called statically in /homepages/35/d258519164/htdocs/www/sites/all/modules/views/views.module on line 879.
strict warning: Declaration of views_handler_field_user::init() should be compatible with views_handler_field::init(&$view, $options) in /homepages/35/d258519164/htdocs/www/sites/all/modules/views/modules/user/views_handler_field_user.inc on line 48.
strict warning: Declaration of views_handler_filter::options_validate() should be compatible with views_handler::options_validate($form, &$form_state) in /homepages/35/d258519164/htdocs/www/sites/all/modules/views/handlers/views_handler_filter.inc on line 589.
strict warning: Declaration of views_handler_filter::options_submit() should be compatible with views_handler::options_submit($form, &$form_state) in /homepages/35/d258519164/htdocs/www/sites/all/modules/views/handlers/views_handler_filter.inc on line 589.
strict warning: Non-static method view::load() should not be called statically in /homepages/35/d258519164/htdocs/www/sites/all/modules/views/views.module on line 879.
strict warning: Declaration of views_handler_filter_user_name::value_submit() should be compatible with views_handler_filter_in_operator::value_submit($form, &$form_state) in /homepages/35/d258519164/htdocs/www/sites/all/modules/views/modules/user/views_handler_filter_user_name.inc on line 144.
strict warning: Declaration of views_handler_filter_user_name::value_validate() should be compatible with views_handler_filter::value_validate($form, &$form_state) in /homepages/35/d258519164/htdocs/www/sites/all/modules/views/modules/user/views_handler_filter_user_name.inc on line 144.

How did you hear about TAG insurance:

Email address: *

Suffix:

First name: *

Middle initial:

Last name: *

Daytime phone: *

Evening phone:

Mobile phone:

Address: *

Address cont.:

City: *

State: *

Zip: *

Driver 1 name: *

Driver 1 license #: *

Driver 1 DOB: *

Driver 1 SSN: *

Driver 2 name:

Driver 2 license #:

Driver 2 DOB:

Driver 2 SSN:

Driver 3 name:

Driver 3 license #:

Driver 3 DOB:

Driver 3 SSN:

Driver 4 name:

Driver 4 license #:

Driver 4 DOB:

Driver 4 SSN:

Any children in the household that do NOT drive?: *

Do you own a home?: *

Who is it insured with?:

Are any vehicles in the household leased?: *

Are you currently insured?: *

If so, with who?:

Expiration:

Liability limits:

Premium:

For how long?:

in months

Vehicle 1 year: *

Vehicle 1 make: *

Vehicle 1 model: *

Vehicle 1 usage: *

Vehicle 1 annual miles (approx): *

Vehicle 1 VIN: *

Vehicle 2 year:

Vehicle 2 make:

Vehicle 2 model:

Vehicle 2 usage:

Vehicle 2 annual miles (approx):

Vehicle 2 VIN:

Vehicle 3 year:

Vehicle 3 make:

Vehicle 3 model:

Vehicle 3 usage:

Vehicle 3 annual miles (approx):

Vehicle 3 VIN:

Vehicle 4 year:

Vehicle 4 make:

Vehicle 4 model:

Vehicle 4 usage:

Vehicle 4 annual miles (approx):

Vehicle 4 VIN:

List all claims, tickets, accidents for the past 5 years: *

Please select your liability protection.: *

Not sure what to select? Leave your selection at "Standard Protection." Once you have received your quote ask your rerpresentative about the coverage options. Superior: 250k / 500k bodily injury; 100k property damage; 250k / 500k under/uninsured; motorist bodily injury Standard: 100k / 300k bodily injury; 50k property damage; 100k / 300k under/uninsured; motorist bodily injury Basic: 50k / 100k bodily injury; 25k property damage; 50k / 100k under/uninsured; motorist bodily injury Minimum: just the minimum values allowed by the state will be used

Collision deductible: *

Comprehensive deductible: *

Rental replacement: *

Lease / gap replacement: *

SR-22 filing: *

Agent email:

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