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Date

Referred by

W/I

Business Name

Business Address

Street Address Address Line 2 City State ZIP Code

FEIN#

Owner(s)

Business Started

Driver #1

M/S

Date of Birth

Driver's License

Social Security Number

DDC

Driver #2

M/S

Date of Birth

Driver's License

Social Security Number

DDC

Accidents/Violations

Vehicle #1 Year

Vehicle #1 Make

Vehicle #1 Model

VIN

Lienholder

Vehicle #2 Year

Vehicle #2 Make

Vehicle #2 Model

VIN#

Lienholder

Prior Insurance Company

Policy Number

Effective

Expiration

Premium

Description of Business

The Independent Agency Advantage

We are insurance advisors.

We want you to make an informed decision on your insurance coverage. Through education, we work to simplify the process so you can make an informed decision based on your needs.

We offer a wide variety of insurance solutions.

Your insurance needs are unique, your insurance coverage should be too. We help you find insurance solutions by offering a wide variety of coverage options.

We are by your side every step of the way.

You’re never on your own when it comes to your insurance. We’re here for you and work with the insurance company on your behalf.

See All the Reasons

Read Our Reviews

“I wouldn’t go to anyone else!”

– Maria F.

“The customer service surpasses anything I ever experienced anywhere else.”

– Nestor L.

“Truly, I can’t recommend Leslie and her team more!”

– Lourdes L.

Read Our Reviews

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