Wallace & Berry Associates, Inc. - An independent Insurance Agency representing the best insurance companies in the business; 'Travelers', 'Chubb', 'Hanover', 'Selective', and 'New York Central Mutual'.

Complete our online form below and submit it to receive a prompt,
confidential quote on automobile insurance...

Please see our Privacy Policy

Name		Present Insurer
Address		Expiration Date
		Annual Premium
Day/Phone	Ext
Evening/Phone	Ext	Credit Score	Excellent Good Fair Poor
Best Time to Call
Email



Vehicle # 1		Vehicle # 2
Make/Model		Make/Model
VIN #		VIN #
Year		Year
Vehicle Use		Vehicle Use
Check all that apply	Air Bags Anti-Lock Brakes Anti-Theft Device Day Time Lights	Check all that apply	Air Bags Anti-Lock Brakes Anti-Theft Device Day Time Lights
Liability Limits	$300,000 $500,000	Liability Limits	$300,000 $500,000
Comprehensive	Yes No	Comprehensive	Yes No
Collision	Yes No	Collision	Yes No



Vehicle # 3		Vehicle # 4
Make/Model		Make/Model
VIN #		VIN #
Year		Year
Vehicle Use		Vehicle Use
Check all that apply	Air Bags Anti-Lock Brakes Anti-Theft Device Day Time Lights	Check all that apply	Air Bags Anti-Lock Brakes Anti-Theft Device Day Time Lights
Liability Limits	$300,000 $500,000	Liability Limits	$300,000 $500,000
Comprehensive	Yes No	Comprehensive	Yes No
Collision	Yes No	Collision	Yes No



Driver # 1		Driver # 2
Date of Birth		Date of Birth
NYS License #		NYS License #
# Years Licensed		# Years Licensed
Marital Status		Marital Status



Driver # 3		Driver # 4
Date of Birth		Date of Birth
NYS License #		NYS License #
# Years Licensed		# Years Licensed
Marital Status		Marital Status

Driving History (past 5 years)

Has any operator in the household had their license suspended or revoked? Yes No

If YES, please enter who, when, and why:

Any Accidents or Moving Violations in Past 5 Years? Yes No

If YES, please enter who, date and type of incident:

Any Comprehensive Claims? (Fire, Theft, etc.) Yes No

If YES, please enter details:

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.