Call Us:
719-275-0305
1116 Main St, Canon City, CO 81212
manager@myaffordableco.com
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AUTO FORM
AFFORDABLE INSURANCE
TELEPHONE LEAD
AUTO INFORMATION
AFFORDABLE INSURANCE TELEPHONE LEAD
DATE
Driver 1
DOB
Driver 2
DOB
Driver 3
DOB
Driver 4
DOB
Occupation
Occupation
DL#
Address
City
ZIP
Highest Grade LEvel
NO GED/DIPLOMA
HIGH SCHOOL/GED
VOCATIONAL/TECH
SOME COLLEGE
COMPLETED COLLEGE
MASTERS
Homeowner
Yes
No
Email
Home #
Work/Cell #
Marital Status
M
S
Div
Sep
W
Acc / Viol in 3 yrs:
New Acc / Viol Dr. 1:
Have you had current insurance for past 6 months with no more than a 30 day lapse?
Yes
No
If so what company?
Renewal Date
Current Premium
Does any driver require an SR- Does any driver require an SR-22?
Yes
No
If so who?
Acc / Viol in 3 yrs:
Year
Auto, RV or MC
Make
Year
Auto, RV or MC
Make
Year
Auto, RV or MC
Make
Model
Model
Model
New Field:
2dr
4dr /
4x4
4x2
25/50
50/100
100/300
New Field:
2dr
4dr /
4x4
4x2
25/50
50/100
100/300
New Field:
2dr
4dr /
4x4
4x2
25/50
50/100
100/300
Comp
Coll
Comp
Coll
Comp
Coll
radio1
FINANCED
LEASED
OWNED
radio2
FINANCED
LEASED
OWNED
RADIO3
FINANCED
LEASED
OWNED
RESULTS
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Contact Us Today
Phone:
719-275-0305
E-mail:
manager@myaffordableco.com
Address:
418 Main St, Canon City, CO 81212
Hours of Operation
Mon - Fri
9:00 am
-
5:00 pm
Sat - Sun
Closed
Contact Us Today
Phone:
719-275-0305
E-mail:
manager@myaffordableco.com
Address:
418 Main St, Canon City, CO 81212
Hours of Operation
Mon - Fri
9:00 am
-
5:00 pm
Sat - Sun
Closed
Browse Our Website
HOME
Auto Insurance
SR22's
Home Insurance
Commercial/Business
Specialty Insurance
About Us
Meet the Staff
Contact Us
Contact Us Today
Phone:
719-275-0305
E-mail:
manager@myaffordableco.com
Address:
1116 Main St, Canon City, CO 81212
Hours of Operation
Mon - Fri
9:00 am
-
5:00 pm
Sat - Sun
Closed
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