SCL Insurance Agency., Inc.
* 1650 Sycamore Avenue, Suite #3, Bohemia, NY 11716 *
* Phone: 631-738-1110 * Fax: 631-738-0312 *
Auto Insurance Quote Request
Basic Address Information
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*
How long:
yrs
Policy expiration date:
Total years with
continuous coverage:
yrs
Driver Information
*
How many drivers are in your household?:
1
2
3
4
More than 4
Driver1
*
Driver2
Driver3
*
Name
*
Relation to Driver 1
Spouse
Child
Parent
Sibling
Other
Spouse
Child
Parent
Sibling
Other
*
Driver License #
*
Gender
Male
Female
Male
Female
Male
Female
*
Marital Status
Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed
Occupation
*
Do you own a home?
Yes
No
Yes
No
Yes
No
*
Date of Birth (i.e. 9/12/60)
*
Total years licensed
*
Tickets in the last 39 months?
0
1
2
3
4
5
6
6+
0
1
2
3
4
5
6
6+
0
1
2
3
4
5
6
6+
*
Accidents in the last 39 months?
0
1
2
3
4
5
6
6+
0
1
2
3
4
5
6
6+
0
1
2
3
4
5
6
6+
Accident Information
#1 Who was driving?
Driver 1
Driver 2
Driver 3
Date:
Injuries?
Yes
No
Accident description:
Rear Ended Other Vehicle
You Were Rear Ended
Backed Into Other Vehicle
You Were Backed Into
Hit Other Vehicle
Your Vehicle Was Hit
Hit Other Property
Hit Pedestrian/Bicyclist
Hit Other While Turning/Merging
Other Driver Ran sign/Signal
Other Driver Cited For Violation
All Other Not At Fault
Damage Amount $
#2 Who was driving?
Driver 1
Driver 2
Driver 3
Date:
Injuries?
Yes
No
Accident description:
Rear Ended Other Vehicle
You Were Rear Ended
Backed Into Other Vehicle
You Were Backed Into
Hit Other Vehicle
Your Vehicle Was Hit
Hit Other Property
Hit Pedestrian/Bicyclist
Hit Other While Turning/Merging
Other Driver Ran Sign/Signal
Other Driver Cited For Violation
All Other Not At Fault
Damage Amount $
Additional Accidents:
Type your comments here.
Ticket Information
#1 Who was driving?
Driver 1
Driver 2
Driver 3
Date:
Ticket description:
Careless/Inattentive driving
Driving with revoked/suspended license
Driving on the wrong side of the highway
Driving over 100 mph
Driving too fast for conditions
Driving while intoxicated/drugs
Driving While Intoxicated
Driving Without a valid drivers license
Exhibition of Speed
Evading a police officer-reckless driving
Failure to have vehicle under control
Failure to yield
Felony involving motor vehicle
Following too close
Hit and Run
Illegal Passing
Lending a license to another
Minor under the influence of alcohol
Open Container; liquor violations
Driving vehicle without owner consent
Other moving violations
Reckless Driving
Refusal of Alcohol Test
Speed Contest
Speeding
Transporting Explosives
Vehicular Manslaughter
Inaccurate license application facts
Impersonating a license applicant
Operation of an uninsured vehicle
Failure to stop when police signals
#2 Who was driving?
Driver 1
Driver 2
Driver 3
Date:
Ticket description:
Careless/Inattentive driving
Driving with revoked/suspended license
Driving on the wrong side of the highway
Driving over 100 mph
Driving too fast for conditions
Driving while intoxicated/drugs
Driving While Intoxicated
Driving Without a valid drivers license
Exhibition of Speed
Evading a police officer-reckless driving
Failure to have vehicle under control
Failure to yield
Felony involving motor vehicle
Following too close
Hit and Run
Illegal Passing
Lending a license to another
Minor under the influence of alcohol
Open Container; liquor violations
Driving vehicle without owner consent
Other moving violations
Reckless Driving
Refusal of Alcohol Test
Speed Contest
Speeding
Transporting Explosives
Vehicular Manslaughter
Inaccurate license application facts
Impersonating a license applicant
Operation of an uninsured vehicle
Failure to stop when police signals
Additional Tickets:
Type your comments here.
Vehicle Information
*
Vehicle 1
Vehicle 2
Vehicle 3
*
Year - (i.e. 1998)
*
Make - (i.e. Chevrolet)
*
Model - (i.e. Cavalier)
*
Sub model - (i.e. Convertible LS)
*
Body style
Sedan
Coupe
Hatch Back
Other
Sedan
Coupe
Hatch Back
Other
Sedan
Coupe
Hatch Back
Other
*
Doors
2
4
2
4
2
4
*
Cylinders
4
6
8
10
12
4
6
8
10
12
4
6
8
10
12
*
Passive Restraints
none
1 airbag
2 airbags
Auto Seatbelts
none
1 airbag
2 airbags
Auto Seatbelts
none
1 airbag
2 airbags
Auto Seatbelts
*
Anti-theft device
none
Car Alarm
Lo-jack
Onstar
Teletrak
The Club
none
Car Alarm
Lo-jack
Onstar
Teletrak
The Club
none
Car Alarm
Lo-jack
Onstar
Teletrak
The Club
*
Principal Operator
Driver 1
Driver 2
Driver 3
Driver 1
Driver 2
Driver 3
Driver 1
Driver 2
Driver 3
*
Used for Business?
Yes
No
Yes
No
Yes
No
*
# of days per week driven to work/school
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
*
One-way daily commute
Miles
Miles
Miles
*
Total Annual Miles
VIN #
*
Property damage liability
$
Minimum
10K
25K
50K
100K
$
Minimum
10K
25K
50K
100K
$
Minimum
10K
25K
50K
100K
*
Bodily Injury Liability (per person/per accident
$
Minimum
15K/30K
50K/100K
100K/300K
300K/300K
250K/500K
$
Minimum
15K/30K
50K/100K
100K/300K
300K/300K
250K/500K
$
Minimum
15K/30K
50K/100K
100K/300K
300K/300K
250K/500K
*
Comprehensive deductible
$
none
100
200
250
500
1000
$
none
100
200
250
500
1000
$
none
100
200
250
500
1000
*
Collision deductible
$
none
100
200
250
500
1000
$
none
100
200
250
500
1000
$
NONE
100
200
250
500
1000
*
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