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Motor Car Insurance Form
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Please completely fill up form below for solid information we need to provide you with an accurate motor vehicle quote at the time you will get or renew your current insurance.

First Name
Last Name
E-Mail Address
Tel. Nos.
Mobile Nos.
Fax. Nos.
Car Model/ Year
Car Make/Brand
Transmission
Registration Due Date, Month
Plate No. Last 3 Digits
Location/Address
Amount of Insurance (FMV)
Is vehicle mortgaged?
Preferred Period of Cover(Advisable is 1 Year)
Message
  

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Contact:

VINIA B. LAPUZ
(Your trustworthy RealtorŪ is also a licensed Non-Life Insurance Consultant)

"We ensure you are covered."

Tel. Nos. (63-2)2115330
Mobile : +63-917-7937893
E-Mail: everra@gmail.com