SAVE MONEY ON YOUR
Automobile INSURANCE!

To properly protect yourself from the always present danger of huge awards for auto liability, it is imperative that you maintain the proper level of coverage for your particular situation.

If you have any doubts about the appropriate level of automobile coverage that's right for you, we have excellent plans available through reputable auto insurers, and we will be happy to help pinpoint the coverage's best suited to your needs.  Simply complete the form below and click the Submit Request button.

 

Policy Holder:

Insured Name:

Address:

City:

State:

Zip:

County:

Date of Birth:

Social Security Number:

Email:

Phone Number:

Current Insurance Information

Do you currently have auto insurance: 

Yes  No

Company Name:

Annual Premium:

Expiration Date:

Have you ever been cancelled or nonrenewed in the last 3 years?:

Yes  No
Coverages

Bodily Injury Liability:

Property Damage Liability:

Medical Payments:

Uninsured/Underinsured Motorist Liability:

Comprehensive Deductible:

Collision Deductible:

Licensed Drivers

1) Primary Driver

 

Name on License:

License State:

License Number:

Date of Birth:

Gender:

Male  Female

Marital Status

Single
Married
Divorced
Widowed

Relationship to Applicant:

Occupation:

Drivers Training:

Yes  No

Tickets and Accidents (Last 5 Years)

2) Driver #2

 

Name on License:

License State:

License Number:

Date of Birth:

Gender:

Male  Female

Marital Status

Single
Married
Divorced
Widowed

Relationship to Applicant:

Occupation:

Drivers Training:

Yes  No

Tickets and Accidents (Last 5 Years)

Other Driver Information
Please provide the names and birthdates of any other residents in your household licensed to drive.
  Name Date of Birth Drivers License Number
1)
2)
3)
Vehicle #1  

Year:

Make:

Model:

VIN:

License State:

Annual Mileage:

# of Doors:

Alarm System:
Yes  No

Air Bag:
Yes  No

Anti-Lock Brakes:
Yes  No

Auto Seatbelts:
Yes  No

Daytime Running Lights:
Yes  No
Vehicle #2

 

Year:

Make:

Model:

VIN:

License State:

Annual Mileage:

# of Doors:

Alarm System:
Yes  No

Air Bag:
Yes  No

Anti-Lock Brakes:
Yes  No

Auto Seatbelts:
Yes  No

Daytime Running Lights:
Yes  No
Vehicle #3  

Year:

Make:

Model:

VIN:

License State:

Annual Mileage:

# of Doors:

Alarm System:
Yes  No

Air Bag:
Yes  No

Anti-Lock Brakes:
Yes  No

Auto Seatbelts:
Yes  No

Daytime Running Lights:
Yes  No

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

 


 

 

Toscano & Slimmer, Inc.
256A West Old Country Road
Hicksville, NY 11801-4011
Phone (516) 931-6200 • Fax (516) 931-4545

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