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Name
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Postal Code
*
Phone
*
Email Address
*
Vehicle #1
Year
*
Make
*
Model
*
Stock
*
stock is considered original or restored to original
No
Yes
Modified
*
has been altered to increase or enhance the performance of the vehicle such as a custom or street rod
No
Yes
Current Market Value
*
Mileage Plan
*
Please select
1,000
3,000
6,000
Vehicle #2 (optional)
Year
Make
Model
Stock
No
Yes
Modified
No
Yes
Current market Value
Mileage Plan
1,000
3,000
6,000
Vehicle #3 (optional)
Year
Make
Model
Stock
No
Yes
Modified
No
Yes
Current Market Value
Mileage Plan
1,000
3,000
6,000
Current limit of liability you maintain
Date of Birth
*
How were you referred to MK Insurance or Tamra Perto
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