(631) 732-8882
Port Jefferson Station, NY
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Insured Information
Your Name
*
Your Date of Birth
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Street Address
City
State
AL
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AR
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DC
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HI
ID
IL
IN
IA
KS
KY
LA
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Zip
Phone Number
*
Email
*
How Did You Find Our Agency?
Social Media
Customer Referral
Google Search
Google Ad
Current Insurance
Do you presently have Auto Insurance?
Yes
No
Do you own your home?
Yes
No
Company Name
Policy Expiration
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
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26
27
28
29
30
31
2021
2022
2023
2024
2025
2026
Annual Premium
Have you been cancelled or non-renewed in the past 3 years?
Yes
No
Coverages
Bodily Injury Liability
15/30
25/50
50/100
100/300
250/500
500/500
Property Damage Liability
5,000
10,000
25,000
50,000
100,000
Medical Payments (PIP)
1,000
2,500
5,000
10,000
20,000
50,000
100,000
Uninsured Motorist Liability
15/30
25/50
50/100
100/300
250/500
Uninsured Motorist Property
5,000
10,000
25,000
50,000
100,000
Underinsured Motorist Liability
15/30
25/50
50/100
100/300
250/500
Underinsured Motorist Property
5,000
10,000
25,000
50,000
100,000
Comprehensive Deductible
No Coverage
250
500
1,000
Collision Deductible
No Coverage
250
500
1,000
Rental Reimbursement
Yes
No
Towing & Labor
Yes
No
Primary Driver
License State
License Number
Gender
Male
Female
Date of Birth
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Marital Status
Married
Single
Divorced
Widowed
Relationship to Applicant
Occupation
Good Student
Yes
No
Driver Training
Yes
No
Tickets and Accidents
(last 5 years)
Other Driver 1
Name
License State
License Number
Gender
Male
Female
Date of Birth
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Marital Status
Married
Single
Divorced
Widowed
Relationship to Applicant
Occupation
Good Student
Yes
No
Driver Training
Yes
No
Tickets and Accidents
(last 5 years)
Other Driver 2
Name
License State
License Number
Gender
Male
Female
Date of Birth
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Marital Status
Married
Single
Divorced
Widowed
Relationship to Applicant
Occupation
Good Student
Yes
No
Driver Training
Yes
No
Tickets and Accidents
(last 5 years)
Other Driver 3
Name
License State
License Number
Gender
Male
Female
Date of Birth
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Marital Status
Married
Single
Divorced
Widowed
Relationship to Applicant
Occupation
Good Student
Yes
No
Driver Training
Yes
No
Tickets and Accidents
(last 5 years)
Vehicle #1 Information
Year
Make
Model
VIN
License State
Annual Mileage
Vehicle #2 Information
Year
Make
Model
VIN
License State
Annual Mileage
Vehicle #3 Information
Year
Make
Model
VIN
License State
Annual Mileage
Vehicle #4 Information
Year
Make
Model
VIN
License State
Annual Mileage
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