The Brandes Insurance Agency | Auto | BUSINESS

Home Information

Name:

Address:

City:

State:

Zip:

Day Phone:

Eve. Phone:

Cell Phone:

E-mail Address:

Best Time To Contact:

AM PM

Method of contact:

Day Phone Eve. Phone Beeper
Cell Email

Current Policy Information

Address to Insure (if other than current address)

Street Address:

City:

State:

Zip:

Amount of Coverage Desired

Year Built:

Roof Type:

Age of Roof:

years

Basement:

Heated Square Feet:

Stories High:

Type of Construction:

Alarm:

Smoker:

Have you made any claims in the past 3 years?

Credit History:

County: (if applicable)

Additional Comments:

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.
I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)

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