Driver One

  Current NY license status:    Valid more than 3 years Valid more than 1 year , less than 3 Valid less than 1 year Suspended Revoked Permit   

   Defensive Driving Course in last 36 Months?  Yes No

     Driver Two 

     Current NY license status:  Valid more than 3 years Valid more than 1 year , less than 3 Not Applicable Valid less than 1 year Suspended Revoked Permit  

    Defensive Driving Course in last 36 Months?  Yes No

     Insured for the last 6 Months?   Yes No   

     Date non-renewed or cancelled in the last 30 days 

     Current auto insurance company:   Other None A Central AIG Insurance Co Aetna Allstate Amica Mutual Insurance Co Encompass Insurance Co Chubb Indemnity Ins Co Cigna Colonial Penn Eagle Erie Farmington GA GEICO General Insurance Company General Accident Ins Co of NY GMAC Great American Insurance Co Hartford Fire Insurance Co Integon Casualty Ins Co Kemper National Insurance Co Liberty Mutual Ins Co Lumberman Mutual Ins Co Merchants Mutual Insurance Co Metropolitan Michigan Miller Mutual National Grange Mutual Insurance Co Nationwide Mutual Insurance Company New Hampshire Insurance Company New York Automobile Ins Plan (NYAIP) New York Casualty Ins Co New York Central Mutual Fire Ins Co Preferred Mutual Progressive Prudential Reliant Royal Safeco State Farm TIG Travelers USAA Utica Mutual Ins Co Windsor Zurich   Current 6 Month total premium?  $ 

      Do you have Homeowners or Renters Insurance Now?   Own House/ Condo Own Mobile Home-10 yrs or newer Live with Parent(s) Rent Other        

     Current Bodily Injury (Liability)  limits: 

   NY State Minimum
  $50,000 per person / $100,000 per accident
  $100,000 per person/$300,000 per accident or $100,000    Combined Single Limits (CSL)
   Greater than $100,000 per person/$300,000 per accident or $100,000 (CSL)
 

               Driving Record

      Accidents (at fault), in the last 40 months                Driver 1             Driver 2    

      Accidents (not at fault), in the last 40 months          Driver 1            Driver 2     
 

      Number of traffic violations  ( If Speeding - MPH over speed limit)  in the last 40 months:

Driver 1     DetailsDriver 2        Details
 

      Year of vehicle 1   2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 Pre 1981 Make of vehicle 1  ACURA ALFA ROMEO AUDI BMW BUICK CADILLAC CHEVROLET CHRYSLER DAIHATSU DODGE EAGLE FORD GEO GMC HONDA HYUNDAI INFINITI ISUZU JAGUAR JEEP LAND ROVER LEXUS LINCOLN MAZDA MERCEDES BENZ MERCURY MITSUBISHI NISSAN OLDSMOBILE PEUGEOT PLYMOUTH PONTIAC PORSCHE SAAB SATURN SUBARU SUZUKI TOYOTA VOLKSWAGEN VOLVO YUGO    Model

      Year of vehicle 2   None 2010 2009 2008 2007 2006 2007 2008 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 Pre 1981 Make of vehicle 2  ACURA ALFA ROMEO AUDI BMW BUICK CADILLAC CHEVROLET CHRYSLER DAIHATSU DODGE EAGLE FORD GEO GMC HONDA HYUNDAI INFINITI ISUZU JAGUAR JEEP LAND ROVER LEXUS LINCOLN MAZDA MERCEDES BENZ MERCURY MITSUBISHI NISSAN OLDSMOBILE PEUGEOT PLYMOUTH PONTIAC PORSCHE SAAB SATURN SUBARU SUZUKI TOYOTA VOLKSWAGEN VOLVO YUGO    Model

      ABS  braking system           vehicle 1    Yes No        vehicle 2   Yes No
      Daytime Running Lights     vehicle 1     Yes No      vehicle 2   Yes No    

      Airbag vehicle 1  None Airbag - Driver Only Airbag - Full Automatic Belts    Airbag vehicle 2  None Airbag - Driver Only Airbag - Full Automatic Belts                     

      Alarm/security system  vehicle 1     None Active Device Passive Device Recovery device VIN Etching Active Device/Recov Device Passive Device/Recov Device Active Device/VIN Etching Passive Device/VIN Etching Recovery Device/VIN Etching Passive Device/VIN Etching/Recov Device Active Device/ Recov Device/VIN Etching
                      
      Alarm/security system  vehicle 2     None Active Device Passive Device Recovery device VIN Etching Active Device/Recov Device Passive Device/Recov Device Active Device/VIN Etching Passive Device/VIN Etching Recovery Device/VIN Etching Passive Device/VIN Etching/Recov Device Active Device/ Recov Device/VIN Etching
                      
      Vehicle 1 use   To work Pleasure Business Artisan      Vehicle 2 use   To work Pleasure Business Artisan

      Vehicle ID # vehicle 1       Vehicle ID #  vehicle 2

      Comp deductible vehicle 1        no coverage 100 250 500 1000         Comp deductible vehicle 2         no coverage 100 250 500 1000

      Collision deductible vehicle 1   no coverage 100 250 500 1000        Collision deductible vehicle 2     no coverage 100 250 500 1000

      Rental vehicle 1       Yes No       Rental vehicle 2     Yes No

      Towing coverage vehicle 1    Yes No        Towing coverage vehicle 2     Yes No

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