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Automobile Insurance Request Form

Name

Address

Email

Phone

Fax

Marital Status

Single

Married

Home Owner?

Yes

No

Currently Insured?

Driver Information #1

Name

Birthdate

Sex (M/F)

# Years U.S. Licensing

Drivers License #

Be specific to tell if accidents are "at fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault" accidents)

Number of Accidents last 3 years

Type of MINOR violations last 3 years

Type of MAJOR violations last 3 years

Daily commute in ONE WAY miles

Does Driver need a SR22 FILING?

Yes

No

If YES to SR22 filing, why needed? (list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)

Name

Birthdate

Sex (M/F)

# Years U.S. Licensing

Drivers License #

Be specific to tell if accidents are "at fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault" accidents)

Number of Accidents last 3 years

Type of MINOR violations last 3 years

Type of MAJOR violations last 3 years

Daily commute in ONE WAY miles

Does Driver need a SR22 FILING?

Yes

No

If YES to SR22 filing, why needed? (list accident/cite)

If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

VEHICLE #1 INFORMATION

Year of Vehicle

Make and Model

Vehicle ID# (for rating accuracy):

Annual Mileage:

Used in business? (Explain, if yes):

VEHICLE #1 COVERAGES

Select Liability Limits

Select Comprehensive Deductible:

Select Collision Deductible:

Full Glass Coverage

YES

NO

Uninsured Motorists Coverage?

Rental Car & Towing Coverage?

YES

NO

Med Pay Coverage?

PIP Coverage

VEHICLE #2 INFORMATION

Year of Vehicle

Make and Model

Vehicle ID# (for rating accuracy):

Annual Mileage:

Used in business? (Explain, if yes):

VEHICLE #2 COVERAGES

Select Liability Limits

Select Comprehensive Deductible:

Select Collision Deductible:

Full Glass Coverage

YES

NO

Uninsured Motorists Coverage?

Rental Car & Towing Coverage?

YES

NO

Med Pay Coverage?

PIP Coverage

Comments of Remarks

(List additional drivers, autos, etc. here)

If More than 2 Vehicles or Drivers, list Additional Vehicles Year, Makes, and Models, and Driver's Ages and Driving records here:

Send my quotation via:

E-Mail

Fax

Regular mail

Call me by Phone!

Java Agency
4515 Main Street P.O. Box 133 Java Village, NY 14083
Phone #: (585) 457-3881 Fax #: (585) 457-3897
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