Baker Insurance Agency - Lennon, Michigan

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Mailing Address:		City/State/Zip:
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Cell:		Contact Preference:
Current / Prior Insurance Company		Expires:
Policy #:		Homeowner:
Drivers
Name:		DOB:
Drivers License #:		Violations:
Name:		DOB:
Drivers License #:		Violations:
Name:		DOB:
Drivers License #:		Violations:
Name:		DOB:
Drivers License #:		Violations:
Vehicles
Vehicle 1
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Vehicle 2
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Vehicle 3
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Vehicle 4
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Any other licensed drivers in the household:
Lien or Loan Holder:
Coverage
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Coll:
Towing:
Have you ever had any bankruptcies, repossessions, or cancellations against you in the past 3 years:

Baker Insurance Agency,
11931 Main Street, P.O. Box 6, Lennon, MI 48449, 800-895-7228, 810-621-3400, 810-621-3406-fax,email

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