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With LeadExchange™ working for you, you'll have confidence that the leads that your web site produces are only from interested consumers.  Below you'll find a sample Auto Insurance lead.  All consumers are required to fill out a standardized questionnaire in order to be considered a valid lead.  To return, please click here

With LeadExchange™ working for you, you'll have confidence that the leads that your web site produces are only from interested consumers.  Below you'll find our standardized Auto Insurance questionnaire.  All consumers are required to fill out the entire questionnaire in order to be considered a valid lead.  To return, please click here

Auto insurance is more than a matter of insuring your vehicle for loss or repairs after an accident.!

Your coverage will protect you against most financial losses that might otherwise be your responsibility to pay.

Instructions:  Please fill in this form as completely as possible in order to ensure that your quote will be as accurate as possible.

First Name

 

Last Name

 

Street Address

 

City

 

State

 

Zip Code

 

Day Phone

 

Evening Phone

 

E-mail Address

 

Best time to call:

 

Who is this quote for?

 

Gender

 

Birthday (mm/dd/yy)

  19

When does your  policy renew?

 

How much are you paying now?

$

Number of Drivers in Your Household?

 

Number of Vehicles in Your Household?

 

How Many Years Have You Had Your Driver's License?

 

Has Your License ever Been Suspended or Revoked?

 

How Many Claims Have You Submitted In The Last 5 Years?

 

What Year Was Your Car Manufactured

 

What Is The Make Of Your Car?

 

What Is The Model Of Your Car?

 

Have you ever been convicted of DUI

 

Would you like an additional quote for any of the following insurance products?

 Life Insurance
 Annuities (Retirement Vehicle)
 Long Term Care Insurance
 Disability Insurance
 Health Insurance
 Group Health Insurance
 Homeowners Insurance
 Home Loans

 

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