Mr.
	Mrs.
	Miss
	
	Name:*		
	Drivers Lic #	
	Soc. Sec. #	
	Address:*	
	City:*		
	State:		
	NY
	

	
	E-Mail:*	
	Occupation:	
	Phone (Day):*	
	Phone (Night):*			
	
	
	Please check here if you are interested in more
	information about:
	
	Persoal Article Floater (Jewelry, Furs, Fine Arts, ETC.)
	Persoal Umbrella Liability Protection
	Dwelling Replacement Cost Estimate
	Special Marketing Programs for Larger Groups

	of Employees, associations or affinity groups.
	Boat/Yacht Insurance
	Flood Insurance
	Travelers Equity Loan


	Automoble:

	Present Insurance Co. 	 
	Expiration Date:	 	
	Annual Premium:		$.00	

		Automobile #1:			Automobile #2:
	Vehicle Year:			Vehicle Year:	
	Make:			Make:		
	Model:			Model:		
	Mileage One Way		Mileage One Way	
	Commute/Annual 		Commute/Annual 		
	Mileage:			Mileage:

		Automobile #3:			Automobile #4:
	Vehicle Year:			Vehicle Year:	
	Make:			Make:		
	Model:			Model:		
	Mileage One Way		Mileage One Way	
	Commute/Annual 		Commute/Annual 		
	Mileage:			Mileage:		


	Drivers in household:
 
		Driver #1:			Driver #2:
	Name:			Name:			
	Date of Birth:		Date of Birth:	
	Married/Single:		Married/Single:	
	Realtionship		Realtionship	
	Years Licensed:			Years Licensed:			
			Vech# 1 2 3 4			Vech# 1 2 3 4
	Percent of use:		Percent of use:	
	
		Driver #3:			Driver #4:
	Name:			Name:			
	Date of Birth:		Date of Birth:	
	Married/Single:		Married/Single:	
	Realtionship		Realtionship	
	Years Licensed:			Years Licensed:			
			Vech# 1 2 3 4			Vech# 1 2 3 4
	Percent of use:		Percent of use:	

	Driving History:

 	Has any driver had his/her license suspended or revoked?YesNo
	
	If, Yes please explain who, when and why:
	
	Any accident or moving violations in the past five years whether
	you or someone else was at fault? Please list driver, date of
	acident and type of incident.

	List all fire, theft, glass and/or vandalism
	losses in the past 3 years. 



	Property:

	Home	Condominium	Renters	(Please check one)

	Year Built:		Style:		 
	Sq. Footage:		Coverage Amt.	$.00
	

	Present Insurance Co. 	 
	Expiration Date:	 	
	Annual Premium:		$.00	

	Construction:Wood	Brick Aluminum/Vinyl Siding
        	     Attached Garage   Basement Garage	
		     Wood Stove   Basement	
		      Percent of Basement Finished?%
		      Feet to hydrant:ft.
		      Miles to firehouse:miles
	
	Protection devices:Smoke Detector fire extinguisher
        	     dead Bolts Fire Alarm   Burglar Alarm		
		     
	Any Losses in the last 3 years? 
	If yes, please explain:


	Thank you, we will reply to you soon.