Sample Insurance Company
Complete Form and proceed to Screen
Personal Liability - AAIS
Sample Insurance (A fictitious entity)
Enter Requested Effective Date
Enter Applicant Name (if name is blank, application will be deleted on Exit)
First  Middle  Last  Suffix 
E-Mail Address 
Current Mailing Address
Address 
  
City 
State Zip 
Years at Current Residence 
Primary Phone 
Work Phone 
Choose type of policy

Identify the Properties to be Covered on this Policy
 

Address 
  
City 
State Zip 

If the mailing address is different from the address of the property to be insured, you must complete the section identifying each property to be covered. Otherwise coverage will be assumed to be for the mailing address.


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