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Willingham Insurance Agency
111 S. 8th Street
Ballinger, Texas 76821
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Phone: 325-365-2516
Fax: 325-365-3667
Toll Free: 800-365-2516
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Online Quote Form

Business & Commercial Auto Vehicle Insurance Quote
	Contact Name:
	Business Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:


	Vehicle Information
	(List all cars you own/lease)
Vehicle 1:	Year	Make/Model	Vin #

	Yearly Mileage	Usage	Alarm


Vehicle 2:	Year	Make/Model	Vin #

	Yearly Mileage	Usage	Alarm


Vehicle 3:	Year	Make/Model	Vin #

	Yearly Mileage	Usage	Alarm


Vehicle 4:	Year	Make/Model	Vin #

	Yearly Mileage	Usage	Alarm

Any Custom equipment of vehicles? (if YES, give their value):



	Current Insurance Information
Insurance Company Name:
Policy Exp. Date:		Premium Amt:
Term:		How long with current?



Debris hauled for others?:
	Trailer Hitch?:
Liability Limit Requested:
Class of Business:

	Driver 1
Name:		Sex:
DL #:		Marital Status:
Date of birth:		Driver's Education?:
S.S.# (optional):		Defensive Driving:
Years Licensed:		Good Student:
Occupation:		SR 22 filing?:
	Driver 2
Name:		Sex:
DL #:		Marital Status:
Date of birth:		Driver's Education?:
S.S.# (optional):		Defensive Driving:
Years Licensed:		Good Student:
Occupation:		SR 22 filing?:
	Driver 3
Name:		Sex:
DL #:		Marital Status:
Date of birth:		Driver's Education?:
S.S.#(optional):		Defensive Driving:
Years Licensed:		Good Student:
Occupation:		SR 22 filing?:
	Driver 4
Name:		Sex:
DL #:		Marital Status:
Date of birth:		Driver's Education?:
S.S.# (optional):		Defensive Driving:
Years Licensed:		Good Student:
Occupation:		SR 22 filing?:
	Accidents / Violations in the last 5 years?
Date	Driver	Violation	Cost ($)




List any DUI convictions, license suspensions or revocations:
How did you hear about us?
Any additional comments or information that might be helpful in your quote:


Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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Online Quote Form

Business & Commercial Auto Vehicle Insurance Quote

Vehicle Information

Current Insurance Information

Driver 1

Driver 2

Driver 3

Driver 4

Accidents / Violations in the last 5 years?