Thank you so much for the opportunity to provide a proposal to insure your Auto and/or Home!!! Please fill out the following at your earliest convenience and I will be happy to email a proposal.
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Personal Information
First Name:
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Last Name:
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Address
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Date of Birth:
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Marital Status:
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Contact Information
Primary Phone:
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Secondary Phone:
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Email Address:
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Additional Information
Policy Expiration Date:
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Spouse's First and Last Name:
Spouse's Date of Birth:
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What year was your roof replaced?:
Best Time to Call:
Auto Information (Up to 4 Vehicles)
Year:
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Make:
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Model:
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Annual Miles Driven:
Vechicle 2
Year:
Make:
Model:
Annual Miles Driven:
Vechicle 3
Year:
Make:
Model:
Annual Miles Driven:
Vechicle 4
Year:
Make:
Model:
Annual Miles Driven:
Home Information
Home Purchase Date:
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Home Value:
Year Built:
Square Footage:
Additional Comments/Notes
Consent is required
Checking this box constitutes my written consent to receive marketing communications and related calls and/or text messages from Allstate and its affiliates including those made via autodialer, automated technology and/or prerecorded or artificial voice message at the above phone number, even if my number is registered on a Do Not Call Registry. I affirm that I am the regular user of the number provided. I understand that message and data rates may apply, that my consent is not a condition of purchase and that I can revoke my consent at any time.
Privacy Statement
Please make sure all of your information is correct before submitting. Please be sure to include the age of your roof if you are a homeowner so that we can provide the most accurate proposal... :-)
Thank you for your submission...we will provide a proposal for your review shortly. Please give us our agency a call at (718)264-2900 if everything looks good!
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Jennifer Igwe Licensed Sales Producer T: 718-264-2900 F: 718-264-8512 22209 Jamaica Avenue Queens Village, New York 11428