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14074 Trade Center Drive, Suite 104  Fishers, IN  46038
Phone: (317) 774-7740     Fax: (317) 774-7741
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AUTO and HOME INSURANCE QUOTE  
 
 

 First Name
 Last Name
  Middle Name

 Address
 City (Indiana only)
                            State (Indiana only at this time)
 Zip Code

  Home Phone
  Daytime Phone (if different)

  Soc Sec Number (see ** disclaimer below)

  Driver's License         Years of driving experience

 
 
DRIVER INFORMATION  

List all of the persons who will be operating your vehicle, INCLUDING yourself:
Driver #1 - Name: 
               D.O.B.:    
                    miles one way work/school       annual miles

Driver #2 - Name: 
               D.O.B.:    
                    miles one way work/school       annual miles

Driver #3 - Name: 
               D.O.B.:    
                    miles one way work/school       annual miles

 
 
VEHICLE INFORMATION  

Vehicle #1 - year   
            Make/Model 
                    VIN number 
                    Note: VIN number gives more accurate quote

Vehicle #2 - year   
            Make/Model 
                    VIN number 
                    Note: VIN number gives more accurate quote

Vehicle #3 - year   
            Make/Model 
                    VIN number 
                    Note: VIN number gives more accurate quote

 
 
HOME INFORMATION  

 Home - Year Built                               Is home mostly brick? Y / N

  Home - County           basement / crawl / slab?

  Home - Township         any animals - type?

  Home - square feet         number of stories?

  Home - coverage amount        
Note: coverage amount on home needs to be 100% replacement cost. Agent will inspect outside of home to determine replacement cost.

 
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Luxor Insurance Group
14074 Trade Center Suite 104
Fishers, IN  46038
 
 
 
 
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