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Since 1919

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Remove A Vehicle Request Form
	Name:
	Address:
	City, State & Zip :
	E-Mail:
Phone #:		Fax #:
Policy Number:
Effective Date of Policy Change:
Make:		Model:
	Vin #:
Driver of this vehicle?:
Any additional comments or information that might be helpful in your request:

Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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JWB INSURANCE

Kelly A. Smith, owner/agent

PO Box 877

324 East Highway, Suite B

Holdenville, OK 74848
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Phone: 405-379-3395
Fax: 405-379-2127
Toll Free: 800-979-3395
Emergency: 405-380-3178
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