Auto Insurance Quote

VIN or Vehicle Description
(ex: SE, GT, V6, 4DR, 4X4, etc)

Comp & Coll Ded
or Liability Only

Discounts (Airbags, ABS, Alarm, etc.)

J.J. Palmtag, Inc

Phone
(402) 873-3344
Fax
(402) 873-3506

E-Mail Us

J.J. Palmtag, Inc. (Nebraska City)

1010 Central Avenue
Nebraska City, NE 68410

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Contact Info.

J.J. Palmtag, Inc

Phone
(402) 873-3344
Fax
(402) 873-3506

E-Mail Me

J.J. Palmtag, Inc. (Nebraska City)

1010 Central Avenue
Nebraska City, NE 68410

Date:

Name:

Phone:

Email:

Garaging Address:

Zip:

Vehicle Information:

Liability Limits (Bodily injury per Person / BI per Accident / Property damage per Accident)

	25,000 / 50,000 / 25,000 (State Required Minimum)
	50,000 / 100,000 / 50,000
	100,000 / 300,000 / 100,000
	Other

Medical Payments

500

1,000

5,000

Other

Uninsured/Underinsured Motorists: Same as above Liability or

Towing

Amt per disablement

Rental Reimbursement

Amt per day

#	Driver Name	Age	Drivers Veh #	Work or Pleasure	Miles to Work	Accidents and Violations for 5 years and/or Drivers License number	Married or Single
1
2
3
4
5

Alumni group?

AARP?

Life?

Muli Pol?

Homeowner?		Do we write?		Custody of Child?
Drivers Ed? Dr#		Honor Roll? Dr#

Current Insurance Company

for

years.

Expires

Premium $

Additional Info:

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J.J. Palmtag, Inc

Phone
(402) 873-3344
Fax
(402) 873-3506

E-Mail Us

J.J. Palmtag, Inc. (Nebraska City)

1010 Central Avenue
Nebraska City, NE 68410

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