Location: The Motter Agency 262 Allegheny Street Jersey Shore , PA 17740
Email: motteragency@motteragency.com
Monday-Friday: 8:30 am – 5:00 pm
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Customer Name:
Year / Make / Model of Auto:
VIN:
Address #1:
Address #2:
City
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Contact Name:
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Fax:
Insured Contact For Questions:
Specific Conditions or Limits:
Certificate Holder:
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Name:
Birth Date:
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Vehicle: (Year, Make, Model)
Miles drive to work (One Way):
Comprehensive/ Collision Deductibles (if wanted):
Business Name:
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Best Method and Time to Contact::
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Year Built:
Sq. Ft:
Acreage:
Age of Roof:
Type of Heat:
Any supplemental heat (wood or pellet stove):
Distance to fire hydrant / fire station:
Other Exposures (Dog, Trampoline, Pool):
Mortgage Holder: