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New Londonís Insurance Professionals


All Lines of Insurance
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Auto Insurance Quote
To ensure a reliable quote, please complete form as accurately as possible.

Personal Information

Name
Social Security Number (###-##-####)
Address
CT Auto Rates are Credit Score based. Failure to provide Social Security Number will result in a higher premium.
City
State
Zip
E-mail Address
Own Home or Condo? Y N
Current Auto Insurance Co.
Current Expiration date
   
If none, Expiration Date
 
Vehicles
 #

Yea r (00)

Make Model 2dr/4dr Miles to Work (one way) Annual Mileage

Comprehensive

Deductible

Collision Deductible

1.

Full Glass Coverage?
Yes

Towing / Labor
Yes
Rental Reimbursement?
Yes
Lease?
Yes
 #

Yea r (00)

Make Model 2dr/4dr Miles to Work (one way) Annual Mileage

Comprehensive

Deductible

Collision Deductible

2.

Full Glass Coverage?
Yes

Towing / Labor Yes Rental Reimbursement?
Yes
Lease?
Yes
 #

Yea r (00)

Make Model 2dr/4dr Miles to Work (one way) Annual Mileage

Comprehensive

Deductible

Collision Deductible

3.

Full Glass Coverage?
Yes

Towing / Labor
Yes
Rental Reimbursement?
Yes
Lease?
Yes
 

Drivers

 Driver 1
 Name

Date of Birth

Gender
Male Female

Marital Status
Married 
Single
Divorced
Moving Violations
( Last 5 Yrs)

# Violations

Date

Amount Paid

At Fault / Not At Fault Accidents (Last 5 Yrs)
 

# Violations

Date

At Fault?
Y N

 Driver 2
 Name

Date of Birth

Gender
Male Female

Marital Status
Married 
Single
Divorced
Moving Violations
( Last 5 Yrs)

# Violations


Date

Amount Paid

At Fault / Not At Fault Accidents (Last 5 Yrs)
 

# Violations

Date

At Fault?
Y N

 Driver 3
 Name

Date of Birth

Gender
Male Female

Marital Status
Married 
Single
Divorced
Moving Violations
( Last 5 Yrs)

# Violations

Date

Amount Paid

At Fault / Not At Fault Accidents (Last 5 Yrs)
 

# Violations

Date

At Fault?
Y N

 

Liability Limit for All Cars

Choose either Split Limits & Property Damage   OR Single Limit Uninsured/Underinsured Coverage
Split Limits Property Damage OR JUST CHOOSE ONE OF THESE:
 ---->
Single Limit  
choose one
Choose 1
None None None Equal to Liability Limit
20,000/40,000 10,000 50,000 Double Liability Limit
25,000/50,000 25,000 100,000

Less than Liability

         (choose 1 below)

50,000/100,000 50,000 300,000 If Split If Single Limit
100,000/300,000 100,000   500,000 20,000
/40,000
50,000
300,000/300,000       25,0 00
/50,000
100,000
250,000/500,000      

50,000
/100,000

300,000
       

100,000
/300,000

 

Credits

Driver Training      Good Student      Defensive Driver Course
Anti-Lock Brakes
        Anti-theft Device
General Remarks
Please enter the letters you see below before sending:

   

Please click on the "Submit Quote" button to send your quote request.
This is not an application for insurance and it does not obligate this agency to issue any policy of insurance.


 

 

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