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 [email protected] 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.