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Insured Information

Insured Name *

Address

City

State/Province

SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOntarioOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming

Zip/Postal Code

Phone

Best time to reach

Select Time 8AM - 12PM 12PM - 4PM 4PM - 7PM

Email *

 

Current Insurance

Do you presently have Auto Insurance?

Yes

No

Renewal Date

 mm

 dd

 yy

 

Coverages

Bodily Injury Liability

Select $25,000 per person/$50,000 per occurrence $50 per person/$100 per occurrence $100 per person/$300 per occurrence $250 per person/$500 per occurrence $5000 per person/$50000 per occurrence

Property Damage Liability

Select $25,000 $50,000 $100,000 $250,000

Medical Payments

Select $1,000 $2,500 $5,000 $10,000 $100,000

Comprehensive Deductible

Select No Coverage $50 $100 $250 $500 $1,000

Collision Deductible

Select No Coverage $100 $250 $500 $1,000

Rental Reimbursement

Yes

No

Towing & Labor

Yes

No

 

Drivers

Please provide the names and birthdates of any other residents in your household licensed to drive.

*SS# optional

 

Name

Marital
Status

Date of Birth

Sex

Drivers
License No.

SS#

1.

Select Married Single

 mm

 dd

 yy

M F

2.

Select Married Single

 mm

 dd

 yy

M F

3.

Select Married Single

 mm

 dd

 yy

M F

4.

Select Married Single

 mm

 dd

 yy

M F

 

Vehicle(s) Information

1. Vehicle Use

Select Pleasure Business Drive to Work

Number of miles driven to work

Year

Select 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Make

Model

2. Vehicle Use

Select Pleasure Business Drive to Work

Number of miles driven to work

Year

Select 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Make

Model

3. Vehicle Use

Select Pleasure Business Drive to Work

Number of miles driven to work

Year

Select 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Make

Model

 

Indicate additional vehicles in the remarks section.

 

Remarks

 

 

 

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Our location

8 East Main Street,

Marcellus, NY 13108

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P: (315) 673-2094

    1 (800) 777-2094 TOLL FREE

F: (315) 673-1121

E: info@reagancompanies.com