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Company Information
Contact Name
Company
Email
Phone - -
Fax - -
Address
Address 2
City
County
Zip
Underwriting Information
Currently Insured? Yes No
Name of Carrier?
How Long Insured?


Type of Business
(Please be specific, and tell how vehicles are used.)
Driver Information
Driver 1 (if more than two drivers, list in remarks)
Driver Name
Gender Yes No
Number/Type
Accidents Last 3yrs
Number/Type
Minor Cites Last 3yrs
Does Driver Need
SR22 FILING? 		Yes No


Date of Birth
Number of Years U.S. Auto License
Number/Type
Major Cites Last 3yrs
Daily Commute
(ONE WAY Miles)
Comments


Driver 2 (if none, leave blank)
Driver Name
Gender Yes No
Number/Type
Accidents Last 3yrs
Number/Type
Minor Cites Last 3yrs
Does Driver Need
SR22 FILING? 		Yes No
Date of Birth
Number of Years U.S. Auto License
Number/Type
Major Cites Last 3yrs
Daily Commute
(ONE WAY Miles)
Comments
Commercial Vehicle Information
Vehicle 1 (if more than two vehicles, list in remarks or call us at 888-553-0021)
Year of Vehicle:
Type (truck, tow-truck, bobtail, etc.)
Gross Vehicle Weight
Radius of Operation
Vehicle ID#
(for accurate rating)


Make & Model:
Length in Feet
Cost New
Current Value


List Special Equipment & Values
Vehicle 1 Coverages
Limits of Liability $500,000 CSL $750,000 CSL
$1 Million CSL
Do you want Medical Coverage? Yes No


Comprehensive
& Collision 		NO Coverage $250 Deductible
$500 Deductible $1,000 Deductible
Uninsured Motorists? Yes No


Vehicle 2 (if more than two vehicles, list in remarks or call us at 888-553-0021)
Year of Vehicle:
Type (truck, tow-truck, bobtail, etc.)
Gross Vehicle Weight
Radius of Operation
Vehicle ID#
(for accurate rating)


Make & Model:
Length in Feet
Cost New
Current Value




List Special Equipment & Values
Vehicle 2 Coverages
Limits of Liability $500,000 CSL $750,000 CSL
$1 Million CSL
Do you want Medical Coverage? Yes No


Comprehensive
& Collision 		NO Coverage $250 Deductible
$500 Deductible $1,000 Deductible
Uninsured Motorists? Yes No


Comments/Remarks


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Albany Contractors Insurance offered for virtually all NY contractors
Albany County NY Day NY Mariaville Lake NY Schaghticoke NY
Rensselaer County NY Delanson NY Mechanicville NY Schenectady NY
Saratoga County NY Delmar NY Medusa NY Schodack NY
Schenectady County NY Duane Lake NY Menands NY Schuylerville NY
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