Marquis Brokerage .:. Insurance Applications

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Marquis Brokerage
All Forms of Insurance

11 Broadway Suite #440

New York, NY 10004

Toll Free: (800) 711-4911
Local: (212) 825-0055
Fax Numbers: (212) 825-0955

(718) 980-5676

Auto Insurance Application

Personal Information

Last Name

First Name

Address

City

State

Zip

Home #

(

)

Work #

(

)

Fax #

(

)

Email Address

How many years have you been licensed?

Date Of Birth

Do you currently hold a NY State Drivers license?

Yes No

Please provide your license number

Marital Status

Married Single

Social Security Number

Automobile Information

Vehicle 1

Year

Make

Model

Vin #

Does your vehicle have any of the following features?

Anti Lock Brakes

Yes No

Air Bags

Yes No

Anti-theft Device

Passive Alarm Active Alarm LOJACK

Passive Restraints

Yes No

Daytime Running Lights

Yes No

Vehicle 2

Year

Make

Model

Vin #

Does your vehicle have any of the following features?

Anti Lock Brakes

Yes No

Air Bags

Yes No

Anti-theft Device

Passive Alarm Active Alarm LOJACK

Passive Restraints

Yes No

Daytime Running Lights

Yes No

Vehicle 3

Year

Make

Model

Vin #

Does your vehicle have any of the following features?

Anti Lock Brakes

Yes No

Air Bags

Yes No

Anti-theft Device

Passive Alarm Active Alarm LOJACK

Passive Restraints

Yes No

Daytime Running Lights

Yes No

Coverage Requested

25/50/10 50/100/50 100/300/50 Other

Liability Only Full Coverage

Driver Information

Please list the licensed drivers in your household

Driver 1

Driver 2

Driver 3

Driver 4

Are you currently insured?

Yes No

If yes, Please provide us with the name of your current insurance carrier

Have you attended a Defensive Driving/Point Reduction class?

Yes No

Your Deductible

$500 $1000

Full Glass

Yes No Deductible

Do you have any tickets for moving violations or accidents in the last 3.5 years?

Yes No

If yes, please provide us with a brief description
(Please do not list parking violations)

Additional Information

An ITS Production