DRIVER INFORMATION
#1
(if more than two drivers, list in remarks)
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
DRIVER INFORMATION
#2 (if none, leave blank)
Name:
Birthdate:
Sex:
# Years U.S. Auto License:
Number & Type of Accidents within last 3 years:
Number & Type of MINOR violations within last 3 years:
Number & Type of MAJOR violations within last 3 years:
Daily commute in ONE WAY miles:
Does Driver need an SR22 FILING?
Yes
No
Comments or Remarks?
COMMERCIAL VEHICLE #1: If more than 2 vehicles, list in remarks or call us at: 585-266-7130
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Length in Feet:
Gross Vehicle Weight:
Cost New: $
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE #1
COVERAGES:
Select Liability Limits
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
COMMERCIAL VEHICLE #2:
Year of vehicle:
Make & Model:
Type (truck, tow-truck, bobtail, etc.):
Length in Feet:
Gross Vehicle Weight:
Cost New: $
Radius of operation:
Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)
VEHICLE ID#
(highly suggested for accurate rating)
VEHICLE INFORMATION FOR UNITS #3-5:
(If none, Leave Blank)
VEHICLE #3
(List Year, Make, Model & Value)
VEHICLE #4
(List Year, Make, Model & Value)
VEHICLE #5
(List Year, Make, Model & Value)
VEHICLE #2 - #5
COVERAGES:
Limits of Liability:
$500,000 CSL
$750,000 CSL
$1 Million CSL
Comprehensive & Collision:
NO Coverage
$250 Deductible
$500 Deductible
$1000 Deductible
Do you want Medical Coverage?
Yes
No
Uninsured Motorists?
Yes
No
Send my quotation via:
E-Mail Fax Regular Mail
Call Me by Phone
Thank you for filling out this form
COMPLETELY!
We value your input as PRIVATE information. Every step has been
taken to insure your privacy, security, and our intent is to release quote information only
to you. We will not give your data to ANY other person or group for sales, marketing,
or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to
release us from any liability should this information be accidentally viewed by others.
Our intention is to maintain your complete privacy.
Yes, I Agree.
Please Send Me a Commercial Vehicle Quote NOW!
Help Us Fight Spam! Type the Numerical Code you see at right, into the empty text box on the left, so we know you are a human. Thanks for your help!
The Online Services of Mazzola Insurance Agency
Mazzola Insurance.org - Fast New York Auto Insurance, Homeowners Insurance, Truck and Boat insurance and Business Insurance quotes for NY residents and businesses. Free online New York personal and business insurance quotes at very low rates. Keywords our customers use to find our services include: New York auto insurance, NY car insurance, New York homeowners insurance, NY boat and yacht insurance, New York contractors insurance, and contractor bonds, low cost New York personal and business insurance, save money on New York insurance, discounts on all NY insurance plans, fast online New York insurance quotes.
* We Provide the Lowest Legal Rates As Allowed In New York.
The Online Services of Mazzola Insurance Agency