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 Select Limits of Liability, Veh. 1\$15/30,000 BI, $5,000 PD $25/50,000 BI, $25,000 PD $50/100,000 BI, $50,000 PD $100/300,000 BI, $100,000 PD $250/500,000 BI, $100,000 PD   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) 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 an Auto Quote NOW! Click Button Below When Done Please Click Only Once . . . May take up to 30 seconds!