New York homeowners insurance from ProActiveBro.com

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On-Line Commercial
Vehicle Quote Form
One Simple Form - takes only 2-3 Minutes!




YOUR PERSONAL DATA:

Your Name:
Business Name:
Street Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
E-Mail (Again, for Accuracy):
Phone:
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)
 
Type of Business:
(Please be specific, and
tell how vehicles are used.)





 
DRIVER INFORMATION #1
(if more than two drivers,
list in remarks)
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
 
DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Auto License:



COMMERCIAL VEHICLE #1:
If more than 2 vehicles, list in remarks
or call us at: 631-482-1860
Year of vehicle: Make & Model:
Type (truck, tow-truck, bobtail, etc.): Cost
New: $
Radius of operation: Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)


VEHICLE ID#
(highly suggested for accurate rating)


VEHICLE #1 COVERAGES:
Select Liability Limits
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
 
COMMERCIAL VEHICLE #2:
Year of vehicle: Make & Model:
Type (truck, tow-truck, bobtail, etc.): Length in Feet:
Gross Vehicle Weight: Cost
New: $
Radius of operation: Value $:
List Special Equipment & Values
(i.e., rack, tool box, etc.)


VEHICLE ID#
(highly suggested for accurate rating)




VEHICLE INFORMATION FOR UNITS #3-5:
(If none, Leave Blank)
VEHICLE #3
(List Year, Make, Model & Value)
VEHICLE #4
(List Year, Make, Model & Value)
VEHICLE #5
(List Year, Make, Model & Value)


VEHICLE #2 - #5 COVERAGES:
Limits of
Liability:
$500,000 CSL
$750,000 CSL
$1 Million CSL
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone


 
Thank you for filling out this form COMPLETELY!


We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a
Commercial Vehicle Quote NOW!





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New York homeowners insurance from ProActiveBro.com

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