Personal Data
Last Name
First
Address
City
State
New York
Zip Code
Phone
Fax (optional)
E-Mail (Required)
Marital Status
Currently Insured
Driver #1 Information
Last Name
First
Date of Birth XX/XX/XXXX
Sex
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License number below to insure quote is LOWEST RATE possible.
Social Security #
Driver License #
Cycle Safety Course
Number of accidents last 3 years
(Explain in comment box below)
Number of MINOR violations last 3 years
(Explain in comment box below)
Number of MAJOR violations last 3 years
(Explain in comment box below)
Comments / Remarks
(Please list accidents, violations, additional drivers, etc)
Driver #2 Information
Last Name
First
Date of Birth XX/XX/XXXX
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 Security #
Driver License #
Cycle Safety Course
Number of accidents last 3 years
(Explain in comment box below)
Number of MINOR violations last 3 years
(Explain in comment box below)
Number of MAJOR violations last 3 years
(Explain in comment box below)
Comments / Remarks
(Please list accidents, violations, additional drivers, etc)
Vehicle #1 Information
Year of vehicle
Type of vehicle
Miles driven to work
Annual Mileage
Number of CC's
Value of vehicle $
Vehicle #1 Coverage
Limit of Liability
Select One
$50/100 BI/50 PD
$100/300 BI/50 PD
Sum
Select One
$25/50
$50/100
$100/300
Comprehensive collision (deductible):
Basic Economic Loss $50,000 | Add $25,000
Vehicle #2 Information
Year of vehicle
Type of vehicle
Miles driven to work
Annual Mileage
Number of CC's
Value of vehicle $
Vehicle #2 Coverage
Limit of Liability
Select One
$50/100 BI/50 PD
$100/300 BI/50 PD
Sum
Select One
$25/50
$50/100
$100/300
Comprehensive collision (deductible):
Basic Economic Loss $50,000 | Add $25,000
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