Morris H. Bannister, Insurance Agency Peekskill NY Life Insurance Quote Request Form

SIAA
Independent Insurance Agent
Trusted Choice™

AUTOMOBILE INSURANCE QUOTE

We would like to provide you with an automobile insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only. (* indicates required information)

Personal Information
* Name:
Address:
City:
State:
Zip:
Social Security:
* Day Phone:	Night Phone:
Best Time To Call:	AM PM
* Email Address:
Occupation:
Employer:
How long at current position:
Premium will be payroll deducted:	Yes

Current Auto Insurance Information
Company Name (not agency):
Policy Expiration Date:	Premium Amount: $
Term:	6 Months 1 Year Other:

Vehicle Information (include all cars you or your family members own or lease)
Car #1	Year	Make	Model	Body Type	Vehicle ID# (VIN)
	19
Drive to school/work? # of miles			Anti-lock Braking System (ABS)		Airbags	Car Alarm
Y N one way			Y N		Y N	Y N

Car #2	Year	Make	Model	Body Type	Vehicle ID# (VIN)
	19
Drive to school/work? # of miles			Anti-lock Braking System (ABS)		Airbags	Car Alarm
Y N one way			Y N		Y N	Y N

Car #3	Year	Make	Model	Body Type	Vehicle ID# (VIN)
	19
Drive to school/work? # of miles			Anti-lock Braking System (ABS)		Airbags	Car Alarm
Y N one way			Y N		Y N	Y N

Car #4	Year	Make	Model	Body Type	Vehicle ID# (VIN)
	19
Drive to school/work? # of miles			Anti-lock Braking System (ABS)		Airbags	Car Alarm
Y N one way			Y N		Y N	Y N

Liability Limit For ALL Cars
Choose either Bodily Injury and Property Damage Bodily Injury Property Damage	or Single Limit Single Limit

Deductibles and Misc.
Car#	Comprehensive Deductible	Collision Deductible	Towing	Loss of Use
1			Yes	Yes
2			Yes	Yes
3			Yes	Yes
4			Yes	Yes

D r i v e r #1	Driver Information (include all licensed drivers in your household)
	Driver's Name
	Drivers License Information	DL#: State: Years Licensed:
	Date of Birth		Relation
	Sex	M F	Married Single
	Courses Completed Last 3 yrs
	Drivers Ed: Y N		Accident Prevention: Y N
	Principal operator (driver) of which car (listed above):

D r i v e r #2	Driver's Name
	Drivers License Information	DL#: State: Years Licensed:
	Date of Birth		Relation
	Sex	M F	Married Single
	Courses Completed Last 3 yrs
	Drivers Ed: Y N		Accident Prevention: Y N
	Principal operator (driver) of which car (listed above):

D r i v e r #3	Driver's Name
	Drivers License Information	DL#: State: Years Licensed:
	Date of Birth		Relation
	Sex	M F	Married Single
	Courses Completed Last 3 yrs
	Drivers Ed: Y N		Accident Prevention: Y N
	Principal operator (driver) of which car (listed above):

D r i v e r #4	Driver's Name
	Drivers License Information	DL#: State: Years Licensed:
	Date of Birth		Relation
	Sex	M F	Married Single
	Courses Completed Last 3 yrs
	Drivers Ed: Y N		Accident Prevention: Y N
	Principal operator (driver) of which car (listed above):

Driver History
Please list ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Driver	Date	Type of Conviction	Fines	Speed Over Limit
				mph
				mph
				mph
				mph

Please list ANY driver who has had license suspensions, revocations or DUI convictions below
Driver	License Suspended or Revoked	DUI Conviction For:
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs
	Suspended Revoked	Alcohol Drugs

Additional Information
In order to provide an accurate quote, my driving history will be checked.	This has my approval: yes no
Some companies give discounts for good credit history.	You can proceed with checking my credit history: yes no

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, such as additional drivers, vehicles, driver histories, etc..., please enter them here.

Click "Submit" to send your quote request.
One of our representatives will contact you as soon as possible.

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