Auto Insurance

We'd love to meet you and find you the perfect solution

Overview

Not sure how much car insurance you need? Overwhelmed by tons of coverage options? No worries. At NEC Insurance Brokerage, we make shopping for car insurance easy.

We’ll help you find the right New York auto insurance rates you can afford, because we can write both:
Preferred auto insurance for drivers with clean records and Non-Standard car insurance for those waiting for their driving records to improve.

At NEC Insurance Agency, Inc. We put the power of the internet to work for you! Please take a moment to answer the following questions. Remember, this information is needed to find the best the best rate for you, so please answer it as accurately and completely as possible.

1) Do you have automobile insurance now? YesNo

2) What is the name of your current auto insurance company:

3) If not listed, please give company name:

4) Current liability limit:

5) How long, in years, have you had auto insurance with this company?

6) How long, have you continuously had auto insurance without a lapse in coverage?
Years
Months

7) When Does Your Policy Renew:

8) How much do you currently pay for your insurance? $

9) Number of drivers to be quoted:

Driver Information:
If there is more than one driver, please complete this form and enter info on 2nd driver on next page.

1) Name on Drivers License: (Last, First MI)

2) Drivers License Number:

State of Issue:

Date of Birth: [MM/DD/YYYY]

3) Social Security Number:

4) To get exact Quote, We have to run your Credit, Do you give us permission to do so ? YesNoJust Estimate

5) Sex: MaleFemale

6) Marital Status:

7) Occupation:

8) Years Licensed:

9) 6 hour accident prevention class ? YesNo

Driving History: 1st driver history. Has this driver had any?

1) Any DUI or DWI in the Last 5 Years? YesNo

2) Has your license been suspended in the last 5 years? YesNo
or revoked? YesNo

3) Number of moving violations in the last 4 years. (Speeding, Stop Sign, Etc.)

4) Number of Accidents in the last 4 years:
# of Points?

5) Total Fines received in the last 4 years:

6) Please detail ALL Violation (tickets) in the Last 4 years for primary driver. Please list the dates of the violations.

Vehicle Information:

1) Is the Vehicle Leased: YesNo

Year:

Make:

Type:

Model:

2) VIN:

3) 4-Wheel Drive? YesNo

4)Anti-Lock Brakes (ABS)? YesNo

5) Alarm Type?

6) Number of Air Bags?

7)Seat Belts?

8)Parking:
Zip of Parking:

9) Annual Miles:

10) Auto Use:

Miles to Work (1 Way)

11) Comprehensive Deductible:

12) Collision Deductible:

13) Please list all other vehicles you would like us to consider:

The following questions concern the type of auto coverage you are requesting. Please answer them as accurately as possible. Please Select From the Following:

1)Bodily Injury:

Property Damage Limit:

2) Uninsured Motorist Coverage:

3) Please indicate Which Features You Would Like:
Medical CoverageTowing CoverageRental Car ReimbursementGlass Coverage

The answer to these basic questions will help us process your information.

1) Do you own or rent your residence:

2) Best Time To Contact:

3) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

1. First Name:

2. Last Name:

3. Phone:

4. Email:

5. Address:

6. Address:

7. City:

8. State:

9. Zip Code:

Scroll to top