Queens, NY Car Insurance
PERSONAL INFORMATION
Name:
Address:
City:
State:
Zip code:
Daytime Phone Number:
Evening Phone Number:
E-Mail address:
Fax Number:
How would you prefer to be contacted
regarding your quote?
Phone
Fax
Mail
E-mail
If you would prefer to be contacted by phone,
please let us know the best time to call.
Do you currently own your home, or rent?
Own
Rent
Social security number:
Highest level of education attained:
Select...
Post-college degree
College degree
Trade degree
High school degree
Did not complete high school
Occupation:
DRIVER INFORMATION
Number of Drivers in Household
Select...
1
2
3
4
Name:
Relationship to applicant:
Sex:
Marital status:
Date of birth (xx/xx/xx):
Number of years licensed:
License Number:
Driver #1
Self
Spouse
Child
Parent
Other
Male
Female
Married
Single
Driver #2
Select One
Self
Spouse
Child
Parent
Other
Male
Female
Married
Single
Driver #3
Select One
Self
Spouse
Child
Parent
Other
Male
Female
Married
Single
Driver #4
Select One
Self
Spouse
Child
Parent
Other
Male
Female
Married
Single
DRIVER HISTORY
Currently insured with (company name not agency):
Have you or any other driver in your household:
How many tickets in the last 3 years?
Had a license suspended or revoked in the last 6 years?
How many accidents in household in last 5 years?
Select...
1
2
3
4+
Yes
No
Select...
1
2
3
4
VEHICLE #1 INFORMATION
Number of vehicles in household
Select...
1
2
3
4
Year:
Make:
Model:
Vehicle ID# (VIN):
(if available)
VEHICLE #2 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
(if available)
VEHICLE #3 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
(if available)
VEHICLE #4 INFORMATION
Year:
Make:
Model:
Vehicle ID# (VIN):
(if available)
COVERAGE OPTIONS
Bodily injury liability:
Select One
$25,000/$50,000
$100,000/$300,000
$250,000/$500,000
$500,000/$500,000
Property damage liability:
Select One
$50,000
$100,000
$250,000
$500,000
Underinsured motorist-bodily injury:
Select One
None
$50,000/$100,000
$100,000/$300,000
$250,000/$500,000
$500,000/$500,000
Underinsured motorist-property damage:
Select One
None
$25,000
$50,000
$100,000
$250,000
COVERAGE DEDUCTIBLES
Comprehensive deductible:
Collision deductible
Vehicle #1
Select One
None
$200
$500
$1,000
Select One
None
$200
$500
$1,000
Vehicle #2
Select One
None
$200
$500
$1,000
Select One
None
$200
$500
$1,000
Vehicle #3
Select One
None
$200
$500
$1,000
Select One
None
$200
$500
$1,000
Vehicle #4
Select One
None
$200
$500
$1000
Select One
None
$200
$500
$1,000
QUESTIONS, COMMENTS, OR ADDITIONAL AUTOMOBILE INFORMATION?
Home
© 2011 Insurance Express, Inc.
