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Maulhardt Insurance Agency 961 N. Rice Ave., Suite 1A, Oxnard, CA 93030 Fax 805 988-8808 Office 988-8810 Name __________________________________________________________ Address ____________________________________________________________ Home Phone _____________________Work Phone__________________________+ Work Address________________________________________________________ Date of Birth _______________________ Married ______________________ Drivers License # ______________________ Annual mileage _____________ Number of citations ______ Number of accidents _______ At fault _____ Model/Year ____________________ Make ________________________________ Vehicle Identification Number (17 digits)____________________________ Bodily Injury ________/________ Property Damage ________ Medical coverage ___________ Towing (yes/no) Comprehensive Deductible ___________ Collision Deductible ___________ Current premium ___________ Current carrier _________________________ Email _______________________________________________________________ |