Auto Inquire
We need some basic info to proceed.
Name
Address
City State Zip
Do you have auto insurance now?
Have you had it for at least six months?
Do you   Own   Rent  Live with parents?
Do you have any major credit cards?
Some companies offer lower pricing tiers depending on information obtained from credit bureaus. To access those tiers, we need your social security number. We will provide you with the source of these consumer reports.
Operator
Name
Date of Birth __/__/__
Tickets
Accidents
Social Security Number
When first licensed
M/YR
Tell us about your driving record
Date
Description of Incident
Vehicle Descriptions
Year
Make
Model
Use
1st
ABS brakes?
Airbags?
Alarm?
VIN Etching?
Homing Device?
Automatic Seat Belts?
2nd
ABS brakes?
Airbags?
Alarm?
VIN Etching?
Homing Device?
Automatic Seat Belts?
3rd
ABS brakes?
Airbags?
Alarm?
VIN Etching?
Homing Device?
Automatic Seat Belts?
4th
ABS brakes?
Airbags?
Alarm?
VIN Etching?
Homing Device?
Automatic Seat Belts?
Coverage desired
Minimum legally required
Minimum plus comprehensive and collision
100/300/100 plus comprehensive and collision on newer vehicles
The Gage Agency, Inc.
112 East Main Street
Middletown, NY 10940
Ph - 800-720-1452   Fax - 845-343-4019