Life Insurance Quote Long – Langlois Insurance Agency

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Name*

Current address*

Street Address City State ZIP Code

Phone*

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Occupation

Effective Date

Requested coverage $*

Number of drivers under 25 years old*

Personal vehicles that you own, excluding antiques

Business vehicles that your company provides you

Antique vehicles

Boats

Personal watercraft

Motorcycles

Off-road vehicles

Properties that you occupy

Rental units that you own

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In order to obtain this quote, an insurance score may be ordered by one or more insurance companies during the rating process. By checking the box below, you are authorizing Ownby Insurance Service, Inc and/or its insurance company partners to order this score as needed in conjunction with obtaining the requested quote.

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