PRIVATE PASSENGER AUTOS INSURANCE APPLICATION

Warning: fopen(/home/noelense/public_html/meiji-info24.com/cache/7a1fe824ba0cc51e321ac07e14d74571) [function.fopen]: failed to open stream: Permission denied in /home/noelense/public_html/meiji-info24.com/exchange/ex_func.php on line 128

Warning: fwrite(): supplied argument is not a valid stream resource in /home/noelense/public_html/meiji-info24.com/exchange/ex_func.php on line 129

Warning: fclose(): supplied argument is not a valid stream resource in /home/noelense/public_html/meiji-info24.com/exchange/ex_func.php on line 130

Warning: fopen(/home/noelense/public_html/meiji-info24.com/cache/ebeb09dc61ac242f67cabc22f076ad67) [function.fopen]: failed to open stream: Permission denied in /home/noelense/public_html/meiji-info24.com/exchange/ex_func.php on line 128

Warning: fwrite(): supplied argument is not a valid stream resource in /home/noelense/public_html/meiji-info24.com/exchange/ex_func.php on line 129

Warning: fclose(): supplied argument is not a valid stream resource in /home/noelense/public_html/meiji-info24.com/exchange/ex_func.php on line 130

Accidents - Losses
How many	none 1 2 3 4
At fault	yes no
Not at fault	none 1 2 3 4
Marital Status	single married separated widowed
Convictions Violation Date Conviction Date  Minor Violations      Major Violations     Speeding 15 MPH or less      Speeding 16 MPH or more     Accidents At Fault Not At Fault   Month / Year  Minor Violations        Major Violations       Speeding 15 MPH or less        Speeding 16 MPH or more

Occasional Operator Information
Age	16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 aver 30
Years Licensed	permit less than 1 year less than 2 years less than 3 years less than 4 years more than 5 years
Gender	male female
Marital Status	single married separated widowed
Defensive Driving
Licensed in NY
Drivers Education

Vehicle Information
Year	77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
Make	Acura Audi Buick BMW Cadillac Chevrolet Chrysler Dodge Infiniti Isuzu Jaguar Jeep Kia Land Rover Lexus Lincoln Nissan Oldsmobile Plymouth Pontiac Porsche Saab Saturn
Model	2 door 4 door wagon convertible
Mileage
Engine Type	gas diesel
Engine Size	4 cyc 6 cyc 8 cyc

Discounts on Vehicles
Alarm	passive active none
Air Bag	driver side dual none
ABS
Etched Glass
Lojack
Day time running Lights
Auto Seat Belts

Use Class
Pleasure
Business
Drives to Work	no under 10 miles a day over 10 miles a day
Is Vehicle Garaged	no at home at office both
Annual Miles

Coverages
Bodily Injury	25/50 50/100 100/300 250/500
Property Damage	10,000 25,000 50,000 100,000
Personal Injury Production Deductible	DED 200 Family DED
Personal Injury Production Options	none guest pip Full additional OBEL
Uninsured Motorist	25/50 50/100 100/300 250/500
Comprehensive Deductible	0 full glass 200 250 500 1000
Medical Payments	none 1000 5000
Collision Deductible	0 200 250 500 1000

Fill out the form again for your next vehicle after filling this form.

ALL FORMS OF INSURANCE

286 NO. FRANKLIN ST. HEMPSTEAD NY 11550

GARY BENNETT

PHONE: 516-483-2814

FAX: 516-483-5218