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On-Line DUI and DWI
Auto Insurance
Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: Must be New York!
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
Yes No
(If yes, list current company below)
 
Current Liability Limits:
(i.e. $100,000; $300,000, etc.)


DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
In order to get all available DISCOUNTS, carriers now run a minor insurance credit check. If you provide Social Security # and Driver's License # below, you will obtain the LOWEST RATE!
Driver 1 Social
Security #:
Driver 1 Driver's
License #:
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 & Type of Accidents last 3 years: Number & Type of MINOR Violations last 3 years:
Number & Type of MAJOR Violations in last 3 years: Comments or
Remarks?


DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
In order to get all available DISCOUNTS, carriers now run a minor insurance credit check. If you provide Social Security # and Driver's License # below, you will obtain the LOWEST RATE!
Driver 2 Social
Security #:
Driver 2 Driver's License #:
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 in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR Violations last 3 years:
Number & Type of MAJOR Violations in last 3 years: Comments or
Remarks?


VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
Number of Doors: Miles Driven to Work?
VEHICLE #1 COVERAGES:
Limits of
Liability:
$25/50 BI / 25 PD $50/100 BI / 50 PD
$100/300 BI / 50 PD $250/500 BI / 100 PD
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Annual Mileage: Used in business?
(Explain, if yes):
VEHICLE #2 COVERAGES:
Limits of
Liability:
$25/50 BI / 25 PD $50/100 BI / 50 PD
$100/300 BI / 50 PD $250/500 BI / 100 PD
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Comments or Remarks:
(List additional drivers, autos, etc. here)


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Stuart E. Cohen Ltd. & Somers Agency - Mill Pond Offices, Suite 109 - 293 Route 100 - Somers, NY 10589
Phone#: 914-276-3222 - Toll Free#: 1-877-576-5200 - Fax#: 914-276-3227
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