Type of Business      Contractor Food Service Landscaping Snowplowing Firewood Non Business Use Service Tow/Service Station Trucking Other    Type of Work you do    

     Has your Insurance been in force for 12 Months & current now? Yes No

    Type of Business  Individual/Sole Prop. Corporation/DBA        Business Name

Business Owner / Named Insured 

 Year vehicle 1   Choose 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 vehicle 1  Choose 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 Vin#

    Vehicle 1 Use Business Personal Business & Personal      Value    Radius of Operations  50 Miles or Less 51 to 100 Miles 101 to 200 Miles 201 to 300 Miles 301 Miles and Over

 Year vehicle 2   Choose 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 vehicle 2  Choose 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 Vin#

    Vehicle 2 Use Business Personal Business & Personal      Value    Radius of Operations  50 Miles or Less 51 to 100 Miles 101 to 200 Miles 201 to 300 Miles 301 Miles and Over

  Total number of accidents (at fault), Within the last 40 months

Driver 1    Details   Driver 2    Details

. Total number of traffic violations within the last 40 months:

Driver 1     DetailsDriver 2        Details

 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

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   Bodily Injury (Liability) coverage you want

NY State Minimum $50,000 per person / $100,000 per accident $100,000 per person/$300,000 per accident Greater than $100,000 per person/$300,000 per accident $100,000 Combined Single Limits (Combined Single Limits) $300,000 Combined Single Limits (CSL) $500,000 Combined Single Limits (CSL) $1,000,000 Combined Single Limits (CSL)  

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