151 Willis Ave, Mineola, NY 11501

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AUTOMOBILE INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Personal Information

Full Name

Address

City

State

Daytime Phone Number

Night Phone Number

Cell Phone Number

Email Address

Confirm Email Address

Current Auto Insurance Information

Company Name (not agency)

Policy Expiration Date

Premium Amount

Policy Term 6 Months 1 Year

Years Insured

Vehicle Information

All cars you or your family members own or lease

Car #1

Car #2

Car #3

Car #4

Liability Limit For ALL Cars

Choose Either Bodily Injury and Property Damage OR Single Limit 

Bodily Injury Select One $25,000/$50,000 $50,000/$100,000 $100,000/$300,000 $250,000/$500,000

Property Damage Select One $25,000 $50,000 $100,000 $500,000

Single Limit Select One $60,000 $100,000 $300,000 $500,000

Deductibles

Car #1 Comprehensive Select One $100 $250 $500

Car #1 Collision Select One $250 $500 $1000

Car #1 Towing?

Car #1 Loss of Use?

Car #2 Comprehensive Select One $100 $250 $500

Car #2 Collision Select One $250 $500 $1000

Car #2 Towing?

Car #2 Loss of Use?

Car #3 Comprehensive Select One $100 $250 $500

Car #3 Collision Select One $250 $500 $1000

Car #3 Towing?

Car #3 Loss of Use?

Car #4 Comprehensive Select One $100 $250 $500

Car #4 Collision Select One $250 $500 $1000

Car #4 Towing?

Car #4 Loss of Use?

Umbrella Liability

Personal Umbrella Coverage Yes No

Umbrella Coverage Amount Select One $1 Million $2 Million $3 Million $5 Million $10 Million

Additional Information

Message or Comments

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