Christy Insurance Agency
134 E Findlay St- Carey, Oh 43316
1230 E Sandusky St
Findlay, OH 45840
ph: F- 419-423-7061 C- 419-396-7993
fax: 419-423-7571
alt: 800-352-2760
ciagency
Print this form and complete as much as possible before visiting our office. You can email it to the email address below as well.
Date_____________________________________
Name 1__________________________________
Birthdate_________________________________
SS#_____________________________________
DL#_____________________________________
Violations_________________________________
*SR22 YES or NO
Other licensed drivers in the house?________
_________________________________________
Address__________________________________
Phone#__________________________________
Prior Insurance____________________________
Vehicle #1_______________________________
VIN#____________________________________
Coverage-Liability Only or Full Coverage: Limits
________________________________________
Deductable: 100 250 500 1000
Vehicle #2____________________________________
VIN#__________________________________________
Coverage-Liability Only or Full Coverage: Limits
______________________________________________
Deductable: 100 250 500 1000
Vehicle #3____________________________________
Coverage-Liability Only or Full Coverage: Limits
______________________________________________
Deductable: 100 250 500 1000
NOTES:________________________________________
______________________________________________
______________________________________________
Any Questions?
Please Call
Findlay Location
419-423-7061
Carey Location
419-396-7993
Referred by___________________________________
Name 2_______________________________________
Birthdate_______________________________________
SS#___________________________________________
DL#___________________________________________
Violations_______________________________________
*SR22 YES OR NO
______________________________________________
Other PH#______________________________________
Lapse Time_____________________________________
Changes in Ohio Driving Laws
Several changes to Ohio's driving laws - most aimed at 16 year-old drivers, were incorporated under House Bill 343, which went into effect April 3, 2007.
All rights reserved by Christy Insurance, a service provided by Farm Accounts Computer Tax Service, Inc, an Ohio Corporation.
Christy Insurance Agency
134 E Findlay St- Carey, Oh 43316
1230 E Sandusky St
Findlay, OH 45840
ph: F- 419-423-7061 C- 419-396-7993
fax: 419-423-7571
alt: 800-352-2760
ciagency