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Welcome to "Managed Competition".
Who says you need to pick 2 out of 3?
JJM Insurance Agency is the answer to your
insurance needs.
In order to get the most accurate quote, we need to
have the following information from you. Please fill
out this form as accurately as possible.
Someone from our office will be in touch with you
shortly.
Thank you for your interest.
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NAME:
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ADDRESS:
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CITY:
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EMAIL:
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PHONE
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CONTACT ME BY:
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TYPE OF POLICY
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Within the past 6 (six) years have you been cancelled
for non payment of premium?
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Within the past 6 (six) years have you been convicted
of driving under the influence of alcohol or drugs, auto
related fraud or vehicular homicide?
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Do you currently have auto insurance?
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How many years have
you been with them?
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If 'YES', when is your renewal date?
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DISCOUNTS
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Please select all that apply.
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Are you a current AAA Member?
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How many miles did you drive last year?
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Do you have a high school or
college student listed on this policy?
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What type of payment plan do you want?
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Have you completed an Advanced
Driver Training program?
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How clean is your SDIP driving record?
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Do you currently have a
homeowners, condo, or renters
policy in force? (If yes, what is the
name of the insurance company?)
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VEHICLE INFORMATION
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YEAR
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MODEL
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MAKE
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Type of Coverage
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Vehicle 1
Vehicle 2
Vehicle 3
Vehicle 4
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POLICY INFORMATION
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UN/UNDERINSURED MOTORISTS
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PROPERTY DAMAGE
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OPTIONAL BODILY INJURY
TO OTHERS
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MEDICAL PAYMENTS
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COLLISION
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COMPREHENSIVE
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SUBSTITUTE TRANSPORTATION
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TOWING & LABOR
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DRIVER INFORMATION
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DRIVERS NAME
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LICENSE NUMBER
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DATE OF BIRTH
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DATE FIRST LICENSED
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Driver 1
Driver 2
Driver 3
Driver 4
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By clicking "Submit" you are allowing us to obtain information about your MA driving record and auto insurance
policy history. In no way is this considered to be binding you with coverage or an offer of auto insurance.
Someone from our office will be in contact with you regarding this quote.
Thank you for choosing JJM Insurance Agency.
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Yes, I am interested in a free Personal Insurance Portfolio Review which includes my
auto insurance, home insurance, umbrella insurance and life insurance policies
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THANK YOU.
SOMEONE FROM OUR OFFICE WILL CONTACT YOU SHORTLY.
WE APPRECIATE THE OPPORTUNITY TO HELP YOU.
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