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The state where you need insurance coverage*
Unfortunately, we are only licensed to provide insurance in California, Oregon and Washington states.
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Are you a member of a Mennonite Church?*
- Yes
- No
Name of church where you are a member:*
Number of Drivers:*
Please enter a number from 1 to 6.
Number of Vehicles:*
Please enter a number from 1 to 6.
Driver 1
Name*
First Last
Date of Birth:*
MM slash DD slash YYYY
Occupation:*
Year Licensed:*
Discounts*
- Good Student (GPA 3.0+)
- Mature Driver (Course Completion Required)
- None
Moving violation in the last 5 years?*
- Yes
- No
Accidents in the last 5 years?*
- Yes
- No
Marital Status:*
Driver 2
Name*
First Last
Date of Birth:*
YYYY dash MM dash DD
Occupation:*
Year Licensed:*
Discounts*
- Good Student (GPA 3.0+)
- Mature Driver (Course Completion Required)
- None
Moving violation in the last 5 years?*
- Yes
- No
Accidents in the last 5 years?*
- Yes
- No
Marital Status:*
Driver 3
Name*
First Last
Date of Birth:*
YYYY dash MM dash DD
Occupation:*
Year Licensed:*
Discounts*
- Good Student (GPA 3.0+)
- Mature Driver (Course Completion Required)
- None
Moving violation in the last 5 years?*
- Yes
- No
Accidents in the last 5 years?*
- Yes
- No
Marital Status:*
Driver 4
Name*
First Last
Date of Birth:*
YYYY dash MM dash DD
Occupation:*
Year Licensed:*
Discounts*
- Good Student (GPA 3.0+)
- Mature Driver (Course Completion Required)
- None
Accidents in the last 5 years?*
- Yes
- No
Moving violation in the last 5 years?*
- Yes
- No
Marital Status:*
Driver 5
Name*
First Last
Date of Birth:*
YYYY dash MM dash DD
Occupation:*
Year Licensed:*
Discounts*
- Good Student (GPA 3.0+)
- Mature Driver (Course Completion Required)
- None
Accidents in the last 5 years?*
- Yes
- No
Moving violation in the last 5 years?*
- Yes
- No
Marital Status:*
Driver 6
Name*
First Last
Date of Birth:*
YYYY dash MM dash DD
Occupation:*
Year Licensed:*
Discounts*
- Good Student (GPA 3.0+)
- Mature Driver (Course Completion Required)
- None
Accidents in the last 5 years?*
- Yes
- No
Moving violation in the last 5 years?*
- Yes
- No
Marital Status:*
Vehicle 1
Vehicle Year:*
Vehicle Make:*
Vehicle Model:*
VIN*
Driver(s):*
Annual Mileage:*
Desired Comprehensive Deductible:*
Desired Collision Deductible:*
Desired Bodily Injury Liability Limits:*
Desired Property Damage Limits:
Is the vehicle altered?*
- Yes
- No
Vehicle 2
Vehicle Year:*
Vehicle Make:*
Vehicle Model:*
VIN*
Driver(s):*
Annual Mileage:*
Desired Comprehensive Deductible:*
Desired Collision Deductible:*
Desired Bodily Injury Liability Limits:*
Desired Property Damage Limits:
Is the vehicle altered?*
- Yes
- No
Vehicle 3
Vehicle Year:*
Vehicle Make:*
Vehicle Model:*
VIN*
Driver(s):*
Annual Mileage:*
Desired Comprehensive Deductible:*
Desired Collision Deductible:*
Desired Bodily Injury Liability Limits:*
Desired Property Damage Limits:
Is the vehicle altered?*
- Yes
- No
Vehicle 4
Vehicle Year:*
Vehicle Make:*
Vehicle Model:*
VIN*
Driver(s):*
Annual Mileage:*
Desired Comprehensive Deductible:*
Desired Collision Deductible:*
Desired Bodily Injury Liability Limits:*
Desired Property Damage Limits:
Is the vehicle altered?*
- Yes
- No
Vehicle 5
Vehicle Year:*
Vehicle Make:*
Vehicle Model:*
VIN*
Driver(s):*
Annual Mileage:*
Desired Comprehensive Deductible:*
Desired Collision Deductible:*
Desired Bodily Injury Liability Limits:*
Desired Property Damage Limits:
Is the vehicle altered?*
- Yes
- No
Vehicle 6
Vehicle Year:*
Vehicle Make:*
Vehicle Model:*
VIN*
Driver(s):*
Annual Mileage:*
Desired Comprehensive Deductible:*
Desired Collision Deductible:*
Desired Bodily Injury Liability Limits:*
Desired Property Damage Limits:
Is the vehicle altered?*
- Yes
- No
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PO Box 878
1110 J St., Reedley, Ca 93654
559.638.2327
mennonite@mennoniteinsurance.com

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Unfortunately, we are only licensed to provide insurance in California, Oregon and Washington states.

Driver 1

Driver 2

Driver 3

Driver 4

Driver 5

Driver 6

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Vehicle 6

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