Automobile Insurance Form

As an independent agent, we represent a number of companies. The following are some basic questions that would allow us to work up a quote for you with the company that is most competitive for you and the vehicles used by your family. Please complete as many fields as possible as the more complete the information, the best chance we have to have the best available coverage for the best available price.

Your Personal Information
Your Name:
E-Mail:
Mailing Address:
City:
State:
Zip:
Home Phone:
Work:
Cell Phone:
How would you like us to contact you?:
Date Of Birth:
Age:
Driver License #
Social Security #
Years Licensed:
Occupation:
Employer:
Is Vehicle Used to Commute to Work:Yes   No
If Yes, Miles One Way to Work
Any accidents or convictions in the last 5 years? Yes   No
Please give date and explanation
Vehicle 1: Year:
Make:
Model:
VIN:
Garage Address is different than Mailing, Please indicate here:
Multiple Policies Discounts
Account Credits are often available with multiple policies with the same company. Should we contact you about:Auto Insurance
Boats
ATV's
Umbrella
Comments/Instructions:
Marital Status:
If Married, Your Spouse Information:
Spouse Name:
Date Of Birth:
Age:
Driver License #
Social Security #
Years Licensed:
Occupation:
Employer:
Is Vehicle Used to Commute to Work:Yes    No
If Yes Miles One Way to Work
Any accidents or convictions in the last 5 years? Yes   No
Please give date and explanation
Vehicle 2: Year:
Make:
Model:
VIN:
Garage Address is different than Mailing, Please indicate here:
If multiple operators in family please indicate % use of vehicle by each operator:
Any Other Operators in the House? If Yes Please Fill In Below.
Name:
Date Of Birth:
Age:
Driver License #
Years Licensed:
Occupation:
Employer:
Is Vehicle Used to Commute to Work:Yes    No
If Yes, Miles One Way to Work:
Is this operator a full time student:Yes    No
If Yes, Miles One Way from Home to School:
Does student use vehicle at school:Yes    No
Any accidents or convictions in the last 5 years?Yes   No
Please give date and explanation
Vehicle 3: Year:
Make:
Model:
VIN:
Garage Address if different than Mailing, please indicate here:
If multiple operators in family please indicate % use of vehicle by each operator:
Please forwards additional operators and vehcile information if more than three.
*

Thank you for taking the time to complete this form

real estate adirondack  adirondack real estate
S. Curtis Hayes, Inc. Insurance and Real Estate
20 Broadway, P.O. Box 1325, Saranac Lake, NY 12983
518-891-2020 · 518-891-2990 FAX
E-Mail: S. Curtis Hayes, Inc.

© S. Curtis Hayes, Inc. Insurance and Real Estate  ·  Designed by Rainbow Graphics
You are the countervisitor. Thank you for stopping by.
adirondack real estate | real estate adirondacks | lake placid real estate | real estate lake placid | saranac lake real estate | real estate saranac lake | adirondack homes properties | adirondack cabins | cabins adirondack | cottages lake placid | adirondack cottage properties | lake placid waterfront homes properties | home insurance | business insurance | auto insurance | boat insurance | motorcycle insurance | vacation home insurance | lake placid waterfront cabins | waterfront land | waterfront cottage properties | waterfront cottage lake placid | lake placid lakefront homes properties | lake placid lakefront cabins | land adirondack | land adirondack mountains | land adirondack new york | vacant land adirondacks | adirondack land | adirondack mountain land | adirondack new york land | adirondacks land | lakefront cabins | lakefront cottage homes | lake placid lakefront cottage homes | adirondack waterfront homes properties | adirondack waterfront cabins | waterfront cabins | waterfront cottage homes | adirondack waterfront homes | adirondack lakefront homes properties | adirondack lakefront cabins | lakefront cabin | lakefront cottage homes | adirondack lakefront cottage homes | saranac lake waterfront homes properties | saranac lake waterfront cabins | waterfront cabins | waterfront cottage homes | saranac lake waterfront cottage | saranac lake lakefront homes properties | saranac lake lakefront cabins | waterfront homes properties | waterfront cabins | waterfront cabins | waterfront cottage homes | waterfront cottage homes | lakefront homes properties | lakefront cabins | new york condominium properties | lake placid | lake placid condos | lake placid, new york | lake placid homes | homes adirondack | lake placid cottages adirondack | lake placid cabins adirondack | adirondack home resorts | adirondack resorts | resort properties | resorts | new york properties | lake placid adirondack | lake placid land | lake placid new york | lake placid lots | homes resorts | lake placid condominims | lake placid townhouses | cabins | cottage homes | Adirondack Waterfront homes properties | Adirondack Waterfront cabins | cabins waterfront | cottage waterfront | waterfront cottage saranac lake | Adirondack Lakefront Properties | Adirondack Lakefront Cabins | Lakefront Cabins Adirondacks | lakefront cottage lake placid | Adirondack Lakefront cottage homes | lodge properties | great camp properties | camps adirondacks | cottages adirondacks | land adirondack | land adirondack mountains | land adirondack new york | land adirondacks | adirondack land | adirondack mountain land | adirondack new york land | adirondacks land | resorts properties | resorts properties adiorndack | lake placid cottage homes | lake placid condo properties | lake placid townhome properties | lake placid new york | lake placid townhouse properties | resorts lake placid | adirondack homes resorts | lake placid properties condominim | lake placid properties townhouse | adirondack homes | adirondack waterfront | waterfront cabins | lakefront cottage homes | adirondack vacation rentals | vacation rentals adirondacks | lake placid vacation rentals | vacation rentals lake placid | saranac lake vacation rentals | vacation rentals saranac lake | adirondack properties | adirondack cabin rentals | cabins rental adirondack | cottage rentals lake placid | adirondack cottage rentals | lake placid waterfront rentals | lake placid waterfront vacations | waterfront rentals | waterfront cottage rentals | lake placid lakefront rentals | lake placid lakefront cabin rentals | lakefront cabin rentals | lakefront cottage rentals | lake placid rentals | adirondack waterfront rentals | vacation rentals adirondack | waterfront cabin rentals | waterfront cottage rentals | rentals lakefront cabins | new york condominium rentals | lake placid condo rentals | lake placid condos | vacation rentals lake placid | rentals lake placid | rentals adirondack | lake placid cottage rentals | lake placid cabins adirondack | lake placid townhome properties | lake placid new york | lake placid townhouse properties | resorts lake placid | adirondack homes resorts | lake placid vacation properties | lake placid vacation townhouses | adirondack vacation homes | adirondack vacation waterfront | vacation waterfront cabins | lakefront vacation cottage homes |