Salvione Insurance Agency, Inc.
Easy Auto Quote Request

Salvione Insurance offers a wide variety of policies from a number of different insurance companies. To find out the cost of automobile insurance for your particular situation, please fill out the form below

We suggest that you print this form and pencil in the requested information. Once you have gathered all the data, enter it into the form using your computer and submit the form electronically, or fax at (518)725-0822. We will contact you with a price quote.

1. Tell Us About Yourself

Name:   Home Phone:
Address:   Business Phone:
City:   Best Time to Call:
State:   Work Home
County:      
Zip:      
         
           
Employer:   *Soc. Sec. No.:
Auto Insurance Exp. Date:   *License Number:
Current Company (not agent):   Date of Birth
*Call us or fax any information with security issues!

2. Your Vehicles and Drivers

Describe all vehicles owned or leased by you

  Vehicle#1 Vehicle#2 Vehicle#3 Vehicle#4
Year
Make
Model
Vehicle identification #
Sub Model (GL)
Body Style (2dr)
Driven to work or school Yes No Yes No Yes No Yes No
  • If yes, miles one way:
  • #of days per week
Used for business Yes No Yes No Yes No Yes No
Miles annually
Anti-theft Yes No Yes No Yes No Yes No
Air bag Yes No Yes No Yes No Yes No
Anti-lock brakes Yes No Yes No Yes No Yes No
Automatic seat belts Yes No Yes No Yes No Yes No
Daytime running lights Yes No Yes No Yes No Yes No

List all drivers who will be covered

  Driver #1 Driver #2 Driver #3 Driver #4
Name:
Relation to you: SELF
Date of birth:
Sex: M F M F M F M F
Marital status:
Age first licensed:
Percent use of vehicle #1: %   + %   + %   +   =100%
Percent use of vehicle #2: %   + %   + %   +   =100%
Percent use of vehicle #3: %   + %   + %   +   =100%
Percent use of vehicle #4: %   + %   + %   +   =100%
Traffic violation description
(within last 40 months -
if none, state so):
Date of violation:
Have you ever had a
DWI or DWUI: 		Yes No      
Have you had driver training? Yes No      
Have you taken a defensive driving course? Yes No      
If yes, then when?      

Are all drivers in your household included above? Yes No
If no, state reason:
If student at school over 100 mi., without car, give name of driver and school:

  Driver #1 Driver #2 Driver #3 Driver #4
Accident or claim description
(within last 3 years - if none, state so):
Date:
         
Who was ticketed? You
Other party 		You
Other party 		You
Other party 		You
Other party
Who was
injured? 		You
Other party 		You
Other party 		You
Other party 		You
Other party
Amount paid for injuries:
Damages to vehicles/property:

3. The Coverage You Need

For the most accurate quotation, refer to your existing policy and check coverages that apply.

   
Single Limit Liability: Per Accident 
Split Limit Liability: 
Property Damage: 
Uninsured/Underinsured:
(Tracks Liability) 
OBEL Yes   No     $25,000 (always)
Med Pay $5,000      $10,000
     
  Vehicle #1 Vehicle #2 Vehicle #3 Vehicle #4
PIP (No Fault) - Additional:
         
Comprehensive Deductible:
         
Collision Deductible:
         
Other: Towing    Rental Reimbursement
         
Remarks:
         

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Salvione Insurance Agency, Inc.
189 N. Main Street Gloversville, NY 12078
Office Hours are from 8:30 AM to 4:30 PM Monday - Friday
Phone: (518)725-8466 or 1-800-725-8466, Fax: (518)725-0822
E-mail: salvione@salvione.com

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