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Butler Insurance Company: Commercial Insurance, Personal Insurance, Auto Insurance, Health Insurance, Bonds and more.

2322 Winford Avenue
Nashville, TN 37211
Local: (615) 777-1165
Toll Free: (800) 253-1165
Fax: (615) 777-1173
getinfo@insurancebutler.com

Auto Insurance Review Online Form: Butler Insurance Company

People

How many licensed drivers are in your household?

Please list each person who lives in your household, including children:

#	Name	Date of Birth	Licensed?
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6.

Feel free to enter any additional information or comments in the space below:

Vehicles

How many vehicles do you (or your spouse) own or lease?

#	Year	Make	Model	Use
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2.
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4.
5.

Have any of the above vehicles you own or lease been customized in any way? No Yes, here's how:

Vehicle # : has been customized or modified as follows:

Have any of the vehicles you own or lease been refinanced or paid off? No Yes, here's how:

Vehicle #: has been Paid off Refinanced through

Feel free to enter any additional information or comments in the space below:

Discounts

Check off the auto insurance discounts to which you believe you're entitled:

Passive restraint system - Requires both airbags and automatic seatbelts.
Anti-Lock brakes - Requires automatic factory-installed anti-lock braking system: ABS.
Defensive driver course - For all drivers who have completed an approved course.
Driver training credit - For licensed drivers under the age of 21.
Good student credit - Applies when youthful drivers maintain a 3.0 or B average.
Resident student - Applies when student is under 21 and over 100 miles away.
Long-term policyholder credit - Applies when you've had a policy with same company for X years.
Loss-free record - Applies when you've gone without an auto claim for 2 years.
Multi-car discount - When there are two or more cars insured on the same policy.
Home & car credit - Discounts off each policy when both are with the same company.
Anti-theft device - Discounts vary by type of device installed.

Enter any comments concerning the above discounts in the space below:

Extra Protection

Check off the extra coverages on which you would like information:

Car rental coverage - in case of an accident, stolen car, or other insured event.
Extra towing & labor coverage - in case of a breakdown, flat tire, etc.
Higher limits of liability protection - in case you're involved in a serious accident.
Higher limits of no-fault protection - in case you're injured in an auto accident.
Special coverage for your auto sound system.
Homeowners, Condo-unit, or renters insurance
Identity-theft insurance
$1,000,000 Umbrella Policy (or higher)
Low-cost Term Life Insurance
Retirement Planning / College Funding
Health insurance / Personal income protection
Business insurance

I am interested in receiving an insurance proposal on my auto and am interested in information on the above protection. Please contact me by ...
Email Regular Mail Phone [Enter numbers below]

Enter any additional comments concerning your insurance in the space below:

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Thank you for taking the time to complete this online review. Its purpose is to assist us in determining if your Homeowner's insurance needs some fine tuning to match up with the current conditions in your life. We promise to get back to you shortly!