Contractors Insurance for Suffolk New York

Contractors Insurance

Suffolk, Nassau & 5 Boros of Long Island New York

www.631ContractorsInsurance.com

631- 467- 6572

Fax 631- 467-5160

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Auto Insurance Quote Form

One Simple Form - takes only 2-3 Minutes to fill out online. You can also print this form here and fax it to us at 631-467-5160 or just give us a call! Your Personal Data
Your Name:
Street Address:
City:
State:	New York
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)

How is Your Credit History? (Some carriers use credit history to qualify)

DRIVER INFORMATION #1
Name:		Birthdate:
Sex (M/F):		# Years U.S. Licensing:
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 Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	If YES to SR22 filing, why needed? (list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)
Name:		Birthdate:
Sex:		# Years U.S. Licensing:
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 Cites last 3 years:
Number & Type of MAJOR Cites last 3 years:		Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?	Yes No	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):
VEHICLE #1 COVERAGES:
Limits of Liability:	$15/30 BI / 10 PD $25/50 BI / 25 PD $50/100 BI / 25 PD $100/300 BI / 100 PD $250/500 BI / 100 PD $500,000 CSL

Comprehensive Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Collision Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Rental Car & Towing Coverage?	YES NO

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:	$15/30 BI / 10 PD $25/50 BI / 25 PD $50/100 BI / 25 PD $100/300 BI /100 PD $250/500 BI /100 PD $500,000 CSL

Comprehensive Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Collision Coverage:	NO Coverage $250 Deductible $500 Deductible $1000 Deductible

Rental Car & Towing Coverage?	YES NO

Comments or Remarks:
(List additional drivers, autos, etc. here)

How may we contact you: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form

Please Note: Insurance coverage cannot be bound without a written binder from our office. No coverage of any kind is bound or implied by submitting information via this online form
We value your privacy. Every precaution has been taken to insure your privacy and security. Our intent is to release information to you only. We will not provide your data to any third party or group for sales, marketing, or any other purposes. By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.
By completing this form, you are acknowledging your understanding of and agreement with these terms.

Yes, I Agree. Please Send Me an Auto Quote NOW!

General Liability l Worker's Comp l Auto & Truck l Bonds l Disability l Builder's Risk