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Auto Insurance Services

1. Driver Information

Driver’s License (front & back)
Full legal name
Date of birth

2. Vehicle Information

Vehicle Registration
Vehicle Title (if available)
VIN (Vehicle Identification Number)
Year, Make, and Model

3. Proof of Address

Utility bill
Lease agreement
Bank statement or official mail

4. Current Insurance (if you have one)

Current auto insurance policy
Insurance ID card
Declaration page

5. Payment Information

Debit or credit card
Bank account details (if using ACH)

6. Additional Information

Driving history (tickets or accidents, if any)
Estimated annual mileage

Note: These details help us find you the best coverage and lowest possible rate.

Before You Apply

Please upload all required documents below
Our licensed agents will review your information and contact you to complete your policy.

First name

Last name

Phone

Submit your questions here

File upload

Disclaimer *

By submitting this form, I agree to provide my information to Amallaz insurance and give permission to be contacted by phone, text, or email about insurance-related opportunities and services. I understand message and data rates may apply, and I can opt out at any time.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.