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Licensed & Bonded
Lic # 0D44460

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Authorized broker for Viking Insurance, Infinity, DriveInsurance from Progressive, AIG, and Bristol West.

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Galaxy Insurance Service Inc
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Galaxy Insurance Service Inc
1001 East Pacific Coast Highway Suite 107
Long Beach, CA 90806
Phone (562) 591-8901, Fax (562) 591-3901
http://www.galaxyinsurance.com/
csr@galaxyinsurance.com
CA Lic #0D44460

Other Then Collision Deductible (Comprehensive)

Applicant Name
Home Phone
City
Drivers Name
Garage Address
State
Zip Code
Occupation
Gender
Marital Status
Minor Violation in 36 Months
Bold = Required field
Work Phone
Mobile Phone
Fax
Mailing Address
City
Zip Code
D.O.B.
Number of Years Driving Experience
Student GPA 3 Point or B Average
Yes
No
Major Violation in 36 Months
60 Months
60 Months
At Fault Accident in 36 Months
Model Year
Make
Model
VIN
Vehicle Usage
Annual Mileage Use
VEHICLE INFORMATION 1
DRIVERS INFORMATION 1
LIMITED OF COVERAGE
PRIOR INSURANCE INFORMATION
Current Company
Policy
Expired  Date
Limit of Liability
How long do you have continuous liability Insurance?

Do you have the following insurance?

How did you hear about our web site?

Collision Deductible

Rental Reimbursement

Towing Reimbursement

DRIVERS INFORMATION 2
At Fault Accident in 36 Months
60 Months
60 Months
Major Violation in 36 Months
Number of Years Driving Experience
D.O.B.
Minor Violation in 36 Months
Marital Status
Gender
Occupation
Drivers Name
DRIVERS INFORMATION 3
At Fault Accident in 36 Months
60 Months
60 Months
Major Violation in 36 Months
Number of Years Driving Experience
D.O.B.
Minor Violation in 36 Months
Marital Status
Gender
Occupation
Drivers Name
DRIVERS INFORMATION 4
At Fault Accident in 36 Months
60 Months
60 Months
Major Violation in 36 Months
Number of Years Driving Experience
D.O.B.
Minor Violation in 36 Months
Marital Status
Gender
Occupation
Drivers Name
VEHICLE INFORMATION 2
Annual Mileage Use
Vehicle Usage
VIN
Model
Make
Model Year
VEHICLE INFORMATION 3
Annual Mileage Use
Vehicle Usage
VIN
Model
Make
Model Year
VEHICLE INFORMATION 4
Annual Mileage Use
Vehicle Usage
VIN
Model
Make
Model Year

Towing Reimbursement

Rental Reimbursement

Collision Deductible

Medical Payment

Uninsured Motorist Liability

Bodily Injury / Person Bodily Injury / Occurrence

Property Damage

Property Damage

Bodily Injury / Person Bodily Injury / Occurrence

LIMITED OF COVERAGE

Other Then Collision Deductible (Comprehensive)

Towing Reimbursement

Rental Reimbursement

Collision Deductible

LIMITED OF COVERAGE

Other Then Collision Deductible (Comprehensive)

Towing Reimbursement

Rental Reimbursement

Collision Deductible

LIMITED OF COVERAGE

Other Then Collision Deductible (Comprehensive)

Effective Date
SR22 / SR1 Filing
Yes
No
License Suspended / Interrupted within 36 Months
Yes
No
Student GPA 3 Point or B Average
Yes
No
SR22 / SR1 Filing
Yes
No
License Suspended / Interrupted within 36 Months
Yes
No
Student GPA 3 Point or B Average
Yes
No
SR22 / SR1 Filing
Yes
No
License Suspended / Interrupted within 36 Months
Yes
No
Student GPA 3 Point or B Average
Yes
No
SR22 / SR1 Filing
Yes
No
License Suspended / Interrupted within 36 Months
Yes
No
Email Address
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