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Insurance Quote Form
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YOUR PERSONAL DATA:

Your Name:
Street Address:
City:
County:
State: (Must be New York)
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)
 
Select Discounts you
will qualify for: 		Multi-units
Snowmobile Safety Course
Snowmobile Club/Association Discount

 
DRIVER INFORMATION #1
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Number & Type of
Accidents within
last 3 years:		 Number & Type of
MINOR Cites within
last 3 years:
Number & Type of MAJOR Cites within last 3 years: 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 Cites within
last 3 years:
Number & Type of MAJOR Cites within last 3 years: Comments or Remarks?

Snowmobile Unit #1 INFORMATION
Year of vehicle: Make & Model:
Type (special features): Cost new: $
List Engine CC size, etc. Current Value: $
Snowmobile #1 COVERAGES:
Limits of
Liability:		 $25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Medical Payments: $1000
$2000 PD
$10,000
 
Uninsured Motorists: $25/50,000
$50/100,000 PD
$100/300,000
 
Snowmobile Unit #2 INFORMATION
Year of vehicle: Make & Model:
Type (special features): Cost new: $
List Engine CC size, etc. Current Value: $
Snowmobile #2 COVERAGES:
Limits of
Liability:		 $25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD
 
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Medical Payments: $1000
$2000 PD
$10,000
 
Uninsured Motorists: $25/50,000
$50/100,000 PD
$100/300,000
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

 
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from Mazzola Insurance.org 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.

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