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On-Line Snowmobile
Insurance Quote Form
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YOUR PERSONAL DATA:

Your Name:
Street Address:
City:
County:
State: (Must be New York)
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If no, type NONE)
 
Select Discounts you
will qualify for:
Multi-units
Snowmobile Safety Course
Snowmobile Club/Association Discount


 
DRIVER INFORMATION #1
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Number & Type of
Accidents within
last 3 years:
Number & Type of
MINOR Cites within
last 3 years:
Number & Type of MAJOR Cites within last 3 years: Comments or Remarks?
 
DRIVER INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Auto License:
Number & Type of
Accidents within
last 3 years:
Number & Type of
MINOR Cites within
last 3 years:
Number & Type of MAJOR Cites within last 3 years: Comments or Remarks?


Snowmobile Unit #1 INFORMATION
Year of vehicle: Make & Model:
Type (special features): Cost new: $
List Engine CC size, etc. Current Value: $
Snowmobile #1 COVERAGES:
Limits of
Liability:
$25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Medical Payments: $1000
$2000 PD
$10,000
 
Uninsured Motorists: $25/50,000
$50/100,000 PD
$100/300,000
 
Snowmobile Unit #2 INFORMATION
Year of vehicle: Make & Model:
Type (special features): Cost new: $
List Engine CC size, etc. Current Value: $
Snowmobile #2 COVERAGES:
Limits of
Liability:
$25/50 BI / 15 PD
$50/100 BI / 50 PD
$100/300 BI / 50 PD
 
Comprehensive
& Collision:
NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Medical Payments: $1000
$2000 PD
$10,000
 
Uninsured Motorists: $25/50,000
$50/100,000 PD
$100/300,000
 
Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

 
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