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  • Personal Information

  • Drivers

  • Gender (Male/Female)First nameLast nameDOB (MM/DD/YYYY)Age 
  • Vehicles

  • YearMakeModelMilesUsage (Work/Pleasure/Business)Coverage (Full coverage/PLPD-Liability only/Unsure) 
  • Current Auto Insurance Carrier

  • Motorcycles

  • YearMakeModelMilesCoverage (Full coverage/PLPD-Liability only/Unsure) 
  • Trailer

  • Boats

  • Notes

By pressing submit, I authorize Speegle Agency to order necessary consumer reports to accurately provide me with the best combination
of rates and coverages.