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Automobile Insurance

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We have several companies to work with. The more information we receive, the better job we will be able to do for you. Please complete the following questionnaire and we will get back to you with a quote. Be sure to complete all sections.

  
     
Please complete the following form:
  Name
      
  Street Address
  
  City
 State
 Postal Code
      
  Phone Number
 (Daytime)
Phone Number
 (Evening)
       
Email Address
  Social Security Number:
          
  Occupation:
          
     
  Vehicles:  
  Make:
 Model:
 Year:
 Use:
 Miles, if for  work:
VIN:
  
  Make:
 Model:
 Year:
 Use:
 Miles, if for work:
VIN:
  
  Make:
 Model:
 Year:
 Use:
 Miles, if for work:
VIN:
  
  Make:
 Model:
 Year:
 Use:
 Miles, if for work:
VIN:
  
     
Drivers:
Name:
 Date of Birth :
 Marital Status:
 License No:
 Relationship to insured:
  
  Name:
 Date of Birth :
 Marital Status:
 License No:
 Relationship to insured:
    
  Name:
 Date of Birth :
 Marital Status:
 License No:
 Relationship to insured:
    
  Name:
 Date of Birth :
 Marital Status:
 License No:
 Relationship to insured:
    
     
Accidents and Violations:
     
  List accidents and violations from the last 4 years. Include Date, what happened, payout and driver's name:
  
     
  Current Coverage:  
     
  Current Insurance Company Company Name:
  
  Bodily Injury Coverage Per Person:
 Coverage Per Accident:
    
  Property Damage Amount:
      
  Uninsured / Underinsured
motorist (UM/SUM)		 Amount:
 Coverage Per Accident:
  
  Personal Injury Protection (PIP) Amount:
  
  Additional (PIP) Amount:
  
Optional Basic Economic Loss
Comprehensive Deductible Amount:
  Collision Deductible Amount:
  
  Death Benefits Amount:
  
  Towing Amount:
  
Rental Cars Coverage Per Day:
 Coverage Per Accident:
   
  Safety Features:  
  Anti Lock Brakes
Air Bags
Daytime Running Lamps
Anti Theft Device   (Describe)
  Auto Seat Belts
   
     

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Copyright © 2011 Tanner - Ibbotson, Inc. All Rights Reserved.
1109 Commons Ave., Cortland, NY 13045
Phone: (607) 756-7531 Fax: (607) 753-3050


 
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