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The Zip Code must be from California 

Number of vehicles:

First vehicle's year ?

2022

Second vehicle's year ?

2022

Third vehicle's year ?

2022

Fourth vehicle's year ?

2022

First vehicle's make?

Second vehicle's make ?

Third vehicle's make ?

Fourth vehicle's make ?

First vehicle's model ?

Second vehicle's model ?

Third vehicle's model ?

Fourth vehicle's model ?

First vehicle's primary use ?

Second vehicle's primary use ?

Third vehicle's primary use ?

Fourth vehicle's primary use ?

What is the comprehensive deductible amount ?

(Most Common)

What is the collision deductible amount ?

(Most Common)

Number of drivers:

Principal driver's date of birth ?

Second driver's date of birth ?

Third driver's date of birth ?

Principal driver's gender ?

Second driver's gender ?

Third driver's gender ?

Principal driver's marital status ?

Second driver's marital status ?

Third driver's marital status ?

Have you had any tickets or incidents ?

What is Your Home Address?

First and Last Name ?

Your E-Mail ?

Lastly, What is Your Phone Number?

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