NY auto insurance from the Lang Agency, LLC
NY auto insurance from the Lang Agency of New York
NY auto insurance from The Lang Agency LLC
NY home  insurance quotes
ny car insurance quotes from The Lang Agency LLC

Come Visit Us in Middletown, NY!
the Lang Agency, LLC
The Lang Agency, LLC
22 County Route 78,
Suite 2
Middletown, NY 10940
(Click for Office Map/Directions)
 
E-Mail:
greg@thelangagency.com

Local Phone:
845-342-5264
(845-342-LANG)

Fax:
845-342-5263


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Auto Insurance Quote

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Motorcyle Ins. Quote

R.V. Insurance Quote

Classic Car Quote

Boat Insurance Quote

Renters Insurance Quote

Condo Insurance Quote

Commercial Auto Quote

Flood Insurance Quote

Personal Umbrella Quote

Life Insurance Quote

Defensive Driver Program

About Our Agency

Office Map/Directions

Policy Service Request

Privacy Notice

The Lang Agency LLC - new york insurance agency
 
 
On-Line Antique, Classic &
Collector's Car Insurance Quote
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
Your "County" is?
State: (Must be New York)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)


DRIVER INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
a DL123 FILING?
Yes No If YES to DL123 filing, why needed?
(list accident/cite)


DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Daily commute
in ONE WAY miles:
Does Driver need
an DL123 FILING?
Yes No Comments or
Remarks?


VEHICLE #1 INFORMATION
Year of vehicle: Make & Model:
Value of vehicle: Additions or Alterations:
Annual Mileage: How Often is Vehicle Used & for What Purposes?
Where is Vehicle Kept, Describe locked garage?: Vehicle Originally equipped? (describe modifications)
VEHICLE #1 COVERAGES:
Select Liability Limits
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?
Yes No   Uninsured
  Motorists Cov.?
Yes No
 
VEHICLE #2 INFORMATION (if none, leave blank)
Year of vehicle: Make & Model:
Value of vehicle: Additions or Alterations:
Annual Mileage: How Often is Vehicle Used & for What Purposes?
Where is Vehicle Kept, Describe locked garage?: Vehicle Originally equipped? (describe modifications)
VEHICLE #2 COVERAGES:
Limits of
Liability:
(Must be the Same as Vehicle #1)
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Do you want
Medical Coverage?
Yes No   Uninsured
  Motorists Cov.?
Yes No
Comments or Remarks:
(List additional drivers, autos, etc. here)


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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.

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