Looking for Cheap Insurance in New York ? Yes, It can actually be reality with us! Looking for Cheap Insurance in New York ? Yes, It can actually be reality with us! Looking for Cheap Insurance in New York ? Yes, It can actually be reality with us! Looking for Cheap Insurance in New York ? Yes, It can actually be reality with us! Looking for Cheap Insurance in New York ? Yes, It can actually be reality with us! Looking for Cheap Insurance in New York ? Yes, It can actually be reality with us!

On-Line Commercial Vehicle Quote Form
One Simple Form - takes only 2-3 Minutes!

Your Personal Data

Your Name:
Street Address:
City:
State: MUST be New York!
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)
Type of Business:
(Please be specific,
and tell how vehicles are used.)
 

DRIVER INFORMATION #1
(if more than two drivers, list in remarks)

Name: Birthdate:
Sex (M/F): # Years U.S. Licensing:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations 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 (M/F): # Years U.S. Licensing:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations 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: 718-441-7777

Year of vehicle: Make & Model:
Type (truck, tow-truck, bobtail, etc.): ILength 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:

Limits of Liability: $500,000 CSL
$750,000 CSL
$1 Million CSL
$100/300 BI / 50 PD
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
Do you want
Medical Coverage?
Yes No   Uninsured
  Motorists Cov.?
Yes No

VEHICLE #2 INFORMATION (if none, leave blank)

Year of vehicle: Make & Model:
Type (truck, tow-truck, bobtail, etc.): ILength 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 #2 COVERAGES:

Limits of Liability: $500,000 CSL
$750,000 CSL
$1 Million CSL
$100/300 BI / 50 PD
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
Do you want
Medical Coverage?
Yes No   Uninsured
  Motorists Cov.?
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!
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