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Please complete this form and include as much information as possible on your coverage needs. One of our knowledgeable agents will then contact you during our regular business hours to discuss your options. If you have any questions, or problems with this form, please contact us directly. Thank you!

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First Name:	Last Name:
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Are you currently a Candor Insurance Group customer? Yes
I am interested in receiving a quote on the following product(s): Auto Homeowner/Renter insurance Life - Term / Indexed Universal Long-term care Health - Group Health - Individual & Family Business Liability Other, please specify below.
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IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail or by leaving a voice mail message. All requests must be conducted through our agency with signed applications or via Internet-based applications provided by our appointed insurance carriers.