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

   Type of Work you do   

   Insured now?, for 12 Months or more? Yes No

  Type of Business            Individual/Sole Prop. Corporation/DBA       

   Name Registered As:  

      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   

  Vehicle 1 Model      

  Vehicle 1 VIN #    

  Vehicle 1 Use       Business Personal Business & Personal  

  Vehicle 1 Value     

  Vehicle 1 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   

  Vehicle 2 Model   

  Vehicle 2 VIN #   

  Vehicle 2 Use       Business Personal Business & Personal     

  Vehicle 2 Value     

  Vehicle 2 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   Details   Driver 2    Details

   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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