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New York
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Currently Insured
Driver #1 Information
Last Name
First
Date of Birth
Sex
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a minor insurance credit check. Please provide Social Security number and Driver's
License number below to insure quote is LOWEST RATE possible.
Social
Driver
Be specific to tell if accidents are 'at-fault' or 'not-at-fault' (carriers
require proof on not-at-fault accidents). Also, be specific as to type of
violations and approximate dates of each in the fields below.
Number of accidents last 3 years
Number of MINOR violations last 3 years
Number of MAJOR violations last 3 years
Comments / Remarks
(Please list accidents, violations, additional drivers, etc.)
Driver #2 Information
Last Name
First
Date of Birth
Sex
In order to get all available DISCOUNTS, carriers now run
a minor insurance credit check. Please provide Social Security number and Driver's
License number below to insure quote is LOWEST RATE possible.
Social
Driver
Be specific to tell if accidents are 'at-fault' or 'not-at-fault' (carriers
require proof on not-at-fault accidents). Also, be specific as to type of
violations and approximate dates of each in the fields below.
Number of accidents last 3 years
Number of MINOR violations last 3 years
Number of MAJOR violations last 3 years
Comments / Remarks
(Please list accidents, violations, additional drivers, etc.)
Vehicle #1 Information
Year of vehicle
Make & Model
Used in business
Miles Driven to Work
Vehicle #1 Coverage
Limits of Liability (listed in thousands)
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$50/100 BI/50 PD
$100/300 BI/50 PD
$250/500 BI/100 PD
PIP
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$50,000
$75,000
$100,000
$150,000
Sum
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25/50
50/100
100/300
250/500
Comprehensive & Collision
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No Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
OBel
Glass
Towing
Rental
Vehicle #2 Information
Year of vehicle
Make & Model
Used in business
Miles Driven to Work
Vehicle #2 Coverage
Limits of Liability (listed in thousands)
Select One
$50/100 BI/50 PD
$100/300 BI/50 PD
$250/500 BI/100 PD
PIP
Select One
$50,000
$75,000
$100,000
$150,000
Sum
Select One
25/50
50/100
100/300
250/500
Comprehensive & Collision
Select One
No Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
OBel
Glass
Towing
Rental
Comments / Remarks
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