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Auto Insurance Protection Questionnaire


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
Required
Last Name
Required
Street
Required
City
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State
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ZIP / Postal Code
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Primary Phone Number
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E-Mail Address
Required
Policy Information
I have a young driver recently licensed or who will be licensed in the next year.
Required

Name
Optional
Date of Birth
Optional
/ /
I have licensed drivers in my household not listed on my auto policy.
Required

Name
Optional
Date of Birth
Optional
/ /
Relationship
Optional
Are there non-residents in your household who frequently use your vehicle?
Required

I have vehicles in my household (other than a company vehicle) that are not insured on my policy with Alan Galvez Insurance.
Required

Owner Name (First & Last)
Optional
Vehicle
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Insurance Company
Optional
I have a company vehicle furnished for my regular use.
Required

I am completely satisfied with my current liability limits.
Required

I would definitely consider raising my deductibles to save money on my policy. Please provide me with a quote.
Required

Non-factory installed equipment (rims, stereo, tv/dvd player, etc.) is not covered without adding coverage. Please provide me a quote.
Required

I have added
Optional
My vehicle is used in business, sales, or deliveries. Please call me to discuss a quote.
Required

I own a pickup or van that contains customized equipment; please make sure I’m covered.
Required

I want rental reimbursement coverage, if not already covered, in the event my car is damaged in an accident. Please call me to add rental car reimbursement.
Required

I have the following items that are NOT currently insured on my policy. Please provide a quote for:
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I want to make sure I am SAVING all the money that I can on ALL of my insurance. I own a home, condo, or rent an apartment, that is not insured with Alan Galvez Insurance. Please quote.
Required

I want towing coverage in the event my car is disabled for any reason. Average cost for theyear is $10
Required

I have a vehicle(s), NOT registered in my or my spouse’s name.
Required

My car is now titled in a trust.
Required

Trust name
Optional
Please send me a FREE insurance ID card for each of my cars.
Required

I need to schedule a review of my insurance plan. Please call me.
Required

Agency Grade Card
Your input is very valuable to us. Please take a moment to tell us how we’re doing.
If you had to grade our agency’s overall performance in providing the service you expect from us, what grade would you give?
Required
If you selected anything less than 5 stars, is there something we could do to improve our score?
Optional
What do you like best about doing business with Alan Galvez Insurance?
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Do we have your permission to use your answer above in the
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May we use your name and city?
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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CONTACT INFO

Alan Galvez Insurance
134 W. Columbus Ave.
Bellefontaine, OH 43311

 (937) 592-4871

 info@galvezinsurance.com

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