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  Date
Time
Location
Weather & Road Conditions
Other Driver Information
- Name
- Address
- Home Phone
- Work Phone
- Driver License #, State
- Ins. Company
- Policy #
Vehicle Information
- Make
- Model
- Year
- Description
- License Plate #, State
Witness Information
- Name(s)
- Address
- Home Phone
- Work Phone
This is not an offer to sell insurance or an advertisement of insurance in any place except the State of New York, United States of America.
Wallace & Berry Associates, Inc. is a licensed Agent in the State of New York. |
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| OFFICES |
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210 MAIN STREET
GOSHEN, NY 10924
845/294-6161 |
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10 LAKE STREET
MONROE, NY 10950
845/782-8284
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a tradition of excellence
in insurance since 1853 |
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