Prescott Insurance & Financial Services

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Prescott Insurance

Request an Auto Quote from Prescott Insurance & Financial Services. In order to save you time, please provide us with the following information and an insurance professional will contact you at your convenience.

Licensed in New York, New Jersey and Connecticut.



Name:

Address:

City:

State:

Zip:

Work phone:

Home phone:

Additional phone:

Email:

Best time to call:
 

Current Insurance Information:

Insurance Company Name:
NOT Agency/Broker

Policy Exp. Date:  

Premium Amt:  

Term:  

How long with current?  
   

Vehicle Information:
 

(List all cars owned or leased)

  

Vehicle 1:  

Year

Make/Model

Vin #
 

Yearly Mileage

Usage

Alarm
 
       

Vehicle 2:  

Year

Make/Model

Vin #
 

Yearly Mileage

Usage

Alarm
 
       

Vehicle 3:  

Year

Make/Model

Vin #
 

Yearly Mileage

Usage

Alarm
 
       

Vehicle 4:  

Year

Make/Model

Vin #
 

Yearly Mileage

Usage

Alarm
 
       

Any Custom equipment on vehicles? (if YES, give their value & indicate which vehicle):  

Coverage Information:

Liability limits for bodily injury & property damage:  

Uninsured Motorist Bodily Injury:  

Deductibles:
 

Comp. & Collision

Towing coverage

Rental Reimb.

Vehicle 1:

Vehicle 2:

Vehicle 3:

Vehicle 4:

Driver Information:

Driver 1:

Name:  

Sex:  

DL # (OPTIONAL):

Martial Status:  

Date of birth:  

Driver's Education?:  

Years Licensed:  

Defensive Driving:  

Occupation:  

Good Student:  
   

SR 22 filing?:  

Driver 2:

Name:  

Sex:  

DL # (OPTIONAL):

Martial Status:  

Date of birth:  

Driver's Education?:  

Years Licensed:  

Defensive Driving:  

Occupation:  

Good Student:  
   

SR 22 filing?:  

Driver 3:

Name:  

Sex:  

DL # (OPTIONAL):

Martial Status:  

Date of birth:  

Driver's Education?:  

Years Licensed:  

Defensive Driving:  

Occupation:  

Good Student:  
   

SR 22 filing?:  

Driver 4:

Name:  

Sex:  

DL # (OPTIONAL):

Martial Status:  

Date of birth:  

Driver's Education?:  

Years Licensed:  

Defensive Driving:  

Occupation:  

Good Student:  
   

SR 22 filing?:  

Accidents / Violations in the last 5 years?
 

Driver 1

Driver 2

Driver 3

Driver 4

Minor violations - speeding, turn, stop sign, red light, etc.

Accidents - non chargeable

Accidents - chargeable

Chargeable Accident Cost($):

Major violations - drunk driving, reckless, hit and run, etc.

Any additional comments or information that might be helpful in your quote:


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Prescott Insurance * 718.627.9300 Brooklyn * 914-621-9300 Port Chester

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