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Contact us

Post Office:
464 Bay Ridge Avenue
Brooklyn, NY 11220-5996

For more information

Telephone:
(718) 836-1100 Local NYC
(800) 253-1490 Toll Free

Fax:
(718) 833-1582

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Automobile Quote
 
Name*: 
Address*: 
 
 Own      Rent      Live with parents
 Prior Address (if less than 5 yrs):
Address: 
 
Home Phone*: 
Work Phone: 
 
# of years at this address? 

Vehicle Information
Vehicle #1: 
Year: 
Make: 
Model: 
Carline: 
VIN: 
Use: 
 ABS
 Air Bags (Driver side only/Both)
 Day Time Running Lights
 Passive Alarm
 Passive Disabling Device
 Lojack
 Window Etching
 Defensive Driver Credit
Vehicle #2: 
Year: 
Make: 
Model: 
Carline: 
VIN: 
Use: 
 ABS
 Air Bags (Driver side only/Both)
 Day Time Running Lights
 Passive Alarm
 Passive Disabling Device
 Lojack
 Window Etching
 Defensive Driver Credit

Driver Information (list all licensed drivers in household)
  Driver #1 Driver #2 Driver #3
Name: Applicant
Date of Birth:
# of Years Licensed:
Married/Single:
License ID #:
Social Security #:
Occupation:

Accidents and Violations
Driver Date Violation/Accident County Amount of
Property Damage

Coverage Information
Liability BI 25/50 50/100 100/300 250/500  
PD 10 25 50 100 250
 
  Vehicle #1 Vehicle #2  
Comp. Ded. 500    1000 500    1000  
Collision Ded. 500    1000 500    1000  
 
Full Glass? Yes    No  

Prior Carrier Information
Insurance Carrier:
Expiration Date:
# of Years:
Assigned Risk?Yes    No
 
Is the company cancelling or non-renewing the policy? If yes, please explain why.
 
* Required fields