Liberty Mutual/ The Next Street Partnership
Liberty Mutual is proud to announce our partnership with The Next Street.
In recognition of their commitment to promoting safe teen driving, we are extending
an additional 10% discount to parents of The Next Street graduates.
I hereby authorize The Next Street to share the below information with Liberty Mutual Insurance for
the purpose of a free no-obligation coverage evaluation.
Signature: _____________________________________________________________Date: _______________________
CUSTOMER INFORMATION
Parent Name:
Last
First
Student’s Name:
Student’s DOB
Address:
City:
State:
Zip:
Primary Phone Number:
Email Address
Best Time to Reach:
AM
PM
EVENING
FOR DRIVER SCHOOL ONLY:
Location:
Representative Name:
Myra Leuci
Liberty Mutual Insurance
Insurance professional
Myra.Leuci@Libertymutual.com
www.libertymutual.com/myraleuci
751 Straits Turnpike
Middlebury, CT 06762
203.598.7177 x.52017
FAX: 603.334.5790
*Discounts and savings are available where state laws and regulations allow, and may vary by state. Certain discounts apply to specific coverage’s only. To the extent
permitted by law, applicants are individually underwritten; not all applicants may qualify. Coverage provided and underwritten by Liberty Mutual Insurance Company and
its affiliates, 175 Berkeley Street, Boston, MA 02116. © 2012 Liberty Mutual Insurance Company. All rights reserved.