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SCL Insurance Agency., Inc.

* 1650 Sycamore Avenue, Suite #3, Bohemia, NY 11716 *

* Phone: 631-738-1110 * Fax: 631-738-0312 *


Auto Insurance Quote Request Form Icon

Auto Insurance Quote Request


Basic Address Information     (Required fields are marked with *)
  Request Auto Insurance Quote
*  Name
*Address
*  City *State Zip:
*  Social Security Number:    

Please supply either a Daytime or Evening Phone Number " best time to call.
    Day Time Number:
    Evening Number:
*  Best Time To Call
    E-mail:
*  Marital Status

Request Auto Insurance

*  Current insurance
    carrier:
*  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  
*Driver License #
*Gender
*Marital Status
Occupation
*Do you own a home?
*Date of Birth (i.e. 9/12/60)
*Total years licensed
*Tickets in the last 39 months?
*Accidents in the last 39 months?

Accident Information

#1   Who was driving?
Date:  Injuries? 
Accident description:
Damage Amount  $

  

#2   Who was driving?  
Date:   Injuries? 
Accident description:
Damage Amount  $
Additional Accidents:

Ticket Information

#1 Who was driving?    
Date: 
Ticket description:

  

#2 Who was driving?    
 Date: 
Ticket description:
Additional Tickets:


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
 
*  Doors
 
*  Cylinders
 
*  Passive Restraints
 
*  Anti-theft device
 
*  Principal Operator
 
*  Used for Business?
 
*  # of days per week driven to work/school
 
*  One-way daily commute
Miles Miles Miles
*  Total Annual Miles
 
  VIN #
 
*  Property damage liability
  $ $ $
*  Bodily Injury Liability (per person/per accident
  $ $ $
*  Comprehensive deductible
  $ $ $
*  Collision deductible
  $ $ $

*  Tell Us About Your Insurance Needs


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