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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:

*Required Field

Click the submit button to submit this form or the reset button
to clear the information and start over.

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

©2001 Northeast Classic Auto Insurance
P.O. Box 287
Monroe, CT 06468
800-866-6440 Fax: 203-459-9791

 

Last modified: 01/11/08