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Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
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Last Name
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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Alternate Phone Number
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E-Mail Address
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Date of Birth
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Gender
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Vehicle Information
Year
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Make
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Model
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VIN #
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Cylinders
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Coverage Options
Coverage
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Comprehensive Deductible
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Collision Deductible
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What percentage of your vehicles total use time is driven by you?
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How many miles will you drive your car annually? (Approximately)
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Bodily Injury Liability
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Property Damage Liability
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Underinsured Motorist - Bodily Injury Limits
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Underinsured Motorist - Property Damage Limits
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Do you currently have insurance?
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Current Insurance Provider
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If no, when did you last have insurance?
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Do you rent or own your home?
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How did you hear about us?
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Any Accidents or Tickets Last 3 years
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Important Notice

In connection with this request for a quote, we may review your credit report or obtain or use a credit-based insurance scored bosed on the information contained in that report.  We may use a third-party in connection with the development of your insurance score.  In addition, we may obtain consumer reports that may include information as to driving and claims experience. 

If you accept this quote, as part of the application process, you will receive a written notification on your application regarding our use of your credit score.  Also, new consumer reports may be ordered at each policy renewal and if ordered will be used to calculate your renewal premium.  I also  need a box  that they check that they have read this.

Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverage.  Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company.  If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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Mailing Address
3915 Independence Dr
Alexandria, LA 71315
Contact Us
318.233-3319
fruggles@trinityinsurancela.com
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318.730.9690
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