Recreation Vehicles

Full Name of Household member:

Relationship to you:

Date of Birth:

Years Licensed:

Miles to Work:

Ins. Company
Name:


Snowmobile, Motorcycle or ATV Quote: Simply fill out the form below and we will process your web application for a free quote directly from Walter O. Rogers Insurance Agency LLC. 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*:

Home Telephone Number*:

Marital Status*:
Married Single

Current Physical Address*:

Current Mailing Address:

City, State Zip Code*:

Email Address:

Licensing Information:

Years licensed? (Not Counting Permit):

(Enter Number in Years)

Licenses owned: Enter License Number and State

License Number:	State:

Your Current Insurance Policy:

Do you have a policy now?*:
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:

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*:

Please Select Vehicle Type*:

Vehicle Year*	Vehicle Make*	Vehicle Model*

Vehicle VIN #*	Weight*	CC's*

Select Coverages*:

Liability
Comprehensive
Collision

Loss Payee:
Yes No

Address of Loss Payee:

For Physical Damage - How long has Vehicle been owned?:

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