Ali Hussein Insurance Agency, Inc.
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Name of Insured:  
Business Name:  
E-Mail Address:  
Home Phone #: [xxx-xxx-xxxx]
Work Phone #: [xxx-xxx-xxxx]
Cell Phone #: [xxx-xxx-xxxx]
Fax #: [xxx-xxx-xxxx]
Years in business Prior insurance company: (if applicable)
Number of Claims in last 3 years: (if any please add more details in the additional comments field)
Business Address:
State: Texas
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List of Commercials Vehicles
Year Vehicle Make Vehicle Model VIN # Value Driver Age MVR
Cargo Coverage (Wreckers and Movers only)
What do you Haul
Cargo Limit   Deductable
Form more locations coverage please fill its information in the additional comments field.
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