INSURANCE

   505A SAN MARIN DRIVE, SUITE 140, NOVATO, CA 94945 

..........................................................

The Fern Family Serving You Since 1966

Fern Insurance Agency
505A San Marin Dr, Suite 140, Novato, California 94945
Phone: (415) 893-0029 Fax: (415) 893-0067

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First Name
Last Name
Address
City
State
ZIP
Phone
Current Auto Insurance Coverage
Email Address
Policy Expiration Date
Car 1 Year
Current Premium
Car 1 Make
Car 1 Model
Car 1 Vehicle ID (VIN)
Annual Miles
One Way Commute Miles
One Way Commute Miles
Annual Miles
Car 2 Vehicle ID (VIN)
Car 2 Model
Car 2 Make
Car 2 Year
One Way Commute Miles
Annual Miles
Car 3 Vehicle ID (VIN)
Car 3 Model
Car 3 Make
Car 3 Year
One Way Commute Miles
Annual Miles
Car 4 Vehicle ID (VIN)
Car 4 Model
Car 4 Make
Car 4 Year
Liability Limit Requested
After Collision Deductible
Towing Coverage
Rental Reimbursement  Coverage
Medical Payments
Uninsured Motorist
Comprehensive Deductible Vehicle 1
Comprehensive Deductible Vehicle 2
Comprehensive Deductible Vehicle 3
Comprehensive Deductible Vehicle 4
Collision Deductible
Driver 1
 
Last Name
First Name
Driver's License #
License State
Years Licensed
Date Of Birth
Marital Status
Occupation
Sex
Sex
Occupation
Marital Status
Date Of Birth
Years Licensed
License State
Driver's License #
First Name
Driver 2
 
Last Name
Relation
Relation
Driver 3
 
Last Name
First Name
Driver's License #
License State
Years Licensed
Date Of Birth
Marital Status
Occupation
Sex
Relation
Driver 4
 
Last Name
First Name
Driver's License #
License State
Years Licensed
Date Of Birth
Marital Status
Occupation
Sex
List Tickets Last 3 Years

Driver #
Date
Type
List any license suspensions, revocations, or DUI convictions in the past 10 years

Driver #
Date of Suspension
Date of DUI
List any accidents in the past 3 years

Driver #
Date
Type
Member of Credit Union
Current AAA Roadside Member
Additional Comments

Fern Insurance Agency
505 A San Marin Dr., Site 140
Novato, CA 94945
(415) 893-0029 Phone
(800) 414-0323 Toll Free
(415) 893-0017 Fax
fernins@novato.net
License #0323744 

Choosing auto insurance from Fern Insurance means choosing wide-ranging coverage that protects you, your family, and your car.

Fern Insurance offering Auto Insurance since 1966.

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