Insurance Quotes: Automobile

Full Name of Household member:

Relationship to you:

Date of Birth:

Years Licensed:

Miles to Work:

Ins. Company
Name:

Automobile Quotes:

Simply fill out the form below and we will process your web application for a free automobile quote directly from Walter O. Rogers Insurance Agency LLC. [NOTE: an asterisk indicates a field that is required to offer you an accurate quote.]

If you have any problems, question or comments, please contact us at (607) 334-8924. We can handle any request you might have right over the phone.

Contact and Personal Information:

Full Name*:

Date of Birth*:

Social Security Number:

Marital Status*:
Married Single

Current Physical Address*:

Current Mailing Address:

City, State Zip Code*:

Email Address:

Previous Address (Less than 3 years):

Previous Address City, State Zip Code:

Home Telephone Number*:

Business Telephone Number:

Licensing and Training Information:

Do you possess a Driver's License?*:
Yes No

Years licensed? (Not Permit):

Enter Your Driver's License Number*:	State:

Have you had Driver's Training?*:
Yes No

If yes, please name the School:

Defensive Driving / 55 ALIVE?*:
Yes No

If yes, please enter date:

Are you Employed?*:
Yes No

If yes, enter one way mileage to work:

Your Current or Last Insurance Policy:

Owned a policy in the last 6 months*:
Yes No

If yes, please enter the Insurer's Name:

Please enter your policy Number:

Enter the policy's Expiration Date:

Your Household:

Is there anyone else in the household with a Driver's License or Permit?*:
Yes No

Is there anyone else in the household Sixteen Years or Older?*:
Yes No

If you answered yes to either of the above questions, enter their information here:

Are there any Physical or Mental Impairments listed on your License or the License of any household member? If Yes, Please enter Name and Condition:

Licensed Operators in Household: Please enter License Numbers and States

Licensed Operator in Household (other than self):	State:

Licensed Operator in Household (other than self):	State:

Driver's History for the last 40 months for all members of Household:

Been in an Accident regardless of fault? If yes, enter information below*:
Yes No

Name of Driver in your Household:

Please enter accident details and dates:

Any Insurance Claims?:
Yes No

Had any Traffic Violations/Convictions? If yes, enter information below*:
Yes No

Name of Driver in your Household:

Please enter violation details and dates:

DWI/ DWAI within the last 10 years? If yes, enter information below*:
Yes No

Name of Driver in your Household:

Please enter date of violation:

Ever had your license suspended? If yes, enter information below*:
Yes No

Name of Driver in your Household:

Please enter date of suspension:

Vehicle Information:

Vehicle is Registered/Titled to*:

Select Vehicle Safety Features:
Anti-Lock Brakes:	Driver Airbag:
Passenger Airbag:	Auto Seat Belts:
Anti-Theft:	Day Time Lights:

Vehicle Year*	Vehicle Make*	Vehicle Model*

Vehicle VIN #*	Which Driver*	Cost New

Select Coverages:

Liability Comprehensive Collision	Full Glass Towing & Labor Rental
Desired Deductible for Comp or Collision (This is not required):

Do you own or rent your home?:
Own Rent

Prior Liability Limits:

By submitting this form, you verify that the information provided here is complete and truthful to the best of your knowledge. You also acknowledge that this system provides only a quote for services, and not the actual price based on a true insurance contract.

Advice: Check your quote form over thoroughly to ensure that you have answered all of the questions.

Note: Quotes provided are entirely based on the information you provide to our offices. Incomplete or false information will result in an inaccurate quote.

Duration: Most quotes are returned within two business days.

Contact Info:

E-mail:
• General Contact
• Walter O. Rogers
• Mark Rogers
• Elke Rogers
• Craig H. Rogers
• Kelly Small
• Karen Smith
• Joy Chensey
Location/ Phone:
26 Fair Street
Norwich, NY 13815
P: (607) 334-8924
F: (607) 334-2538

55 Christina Street
Little Ferry, NJ 07643
P: 201-641-2233