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APPLICATION FOR AUTOMOBILE INSURANCE

WESTERN GENERAL INSURANCE COMPANY5230 Las Virgenes Road, Calabasas, california 91302 APPLICATION FOR AUTOMOBILE INSURANCEPage 1 of 4 Phone: (800) 758-3311 Phone: (818) 880-5433 Fax: (818) 880-9273 PROPOSED EFFECTIVE DATE:TIME: AM PMCOVERAGE TERM:APPLICANTREGISTERED OWNER:ADDRESS:CITY:TYPE OF RESIDENCY:STATE:ZIP:LENGTH OF RESIDENCY:HOME PHONE:CELL PHONE:PRODUCERPRODUCER NAME:ADDRESS:CITY:PRODUCER CODE:STATE:ZIP:PHONE:PROOF OF INSURANCE (SR): ( california Filing Only - please attach copies) SR1P - Accident for: SR22 - All other reasons for:WORK PHONE:E-MAIL:List all drivers including applicant and household members over 14 years old.

WESTERN GENERAL INSURANCE COMPANY 5230 Las Virgenes Road, Calabasas, California 91302 APPLICATION FOR AUTOMOBILE INSURANCE Page 1 …

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