267 New Dorp Lane, Second Floor, 10306 Staten Island,
Welsh Agency, Inc.
 
josephine@welshagency.com
Call Us: (718) 351-6000
 
 
 
 
 
 

Auto Quotation

 
United States of America
 
Date of Birth:
 
 
Do You Presently Have Insurance?
 Yes 
 No 
Do You Own a House or Rent
 Own 
 Rent 
Do You Have 6 Months Prior Insurance?
How many Drivers in the Household?
Are All Licensed over 3 Years?
 Yes 
 No 
Any Accidents or Violations in the Past 3 1/4 Years?
 Yes 
 No 
Did Any Licensed Drivers Take Defensive Driving?
 Yes 
 No 
Married or Single
 Married 
 Single 
Ages of All Licensed Drivers
Do You Have Any Children In The Household Who Have A License?
What Vehicles Are You Looking To Insure?
Vin Number
What Limits Are You Looking For?
 25/50 
 50/100 
 100/300 
Do You Need Comp & Collison
 Yes 
 No 
What Deductible?
If No Comp or Collision Do You Have Passive Restraints?
Are The Following In Your Vehicle?
 
 
 
 
 
 
 
 
 
 
How did you hear about us?