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Classic Car Insurance Quote
To ensure a reliable quote, please complete form as accurately as possible.

Personal Information
Primary Driver’s Name:
Date of birth:
Today’s date:
Street:
City: State:Zip:
Home Phone: Work Phone:  
 Fax Number:
E-Mail Address*: (Required)

Car To Be Insured: 

(If you have more than one car, please list info in the "Questions Or Comments" section at the bottom of this form.)
Year: Make:
Model:
Value:
Annual Mileage:
Stock    Modified
Is the car to be garaged?

Yes

No

List any traffic violations, accidents and the dates:

Complete if you are married:
Spouse’s name:
Spouse’s date of birth:
List any of your spouse’s traffic violations, accidents and the dates:

Complete for children of driving age living at home:

Number of children 

16-25 years old:
List any of your children’s traffic violations, accidents and the dates:

Current insurance information:
How many regular use vehicles do you own? 
List year make and model of each vehicle:
What is your current amount of liability coverage?    
What is your current amount of uninsured motorist coverage?
Questions or comments:


This is not an application for insurance and it does not obligate this agency to issue any policy of insurance.  

 

©2010, Northeast Classic Auto Insurance
P.O. Box 287
Monroe, CT 06468
800-866-6440 Fax: 203-459-9791