Name: C.L. Van Deventer Insurance Agency
Address: 123 W. Chicago Road, Sturgis, MI, 49091, US
Telephone: (269) 651-8066

Name
First Last
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Date of Birth
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Driver’s license
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Address
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Vehicle information
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Type of coverage you are looking for: (Full coverage? liability?)
Deductibles: (standard is 250/500)
Any lienholders:
Current health carrier:
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Who else will be on the policy:
Marital status: (if married please provide the name, dob, and driver’s license number)

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