IMPORTANT INFO:
In addition to submitting this form online, this form can be printed and faxed to:
Fax: (212) 937-3923

or call today for an
EXPRESS PHONE QUOTE:
888-ARMofNY (276-6369)
 and talk to an insurance specialist.

- LOW PRICES
- LOW DOWN PAYMENT
- LOW MONTHLY PAYMENTS
- IMMEDIATE COVERAGE
- "A+" RATED CARRIERS
- PROFESSIONAL SERVICE
- PAYMENT PLANS
- CREDIT CARDS


COVERAGE DEFINITIONS

Bodily Injury/Guest Passenger (BI/GP)
 Pays when an insured person is legally liable (responsible) for bodily injury or death caused by your vehicle or your operation of most non-owned vehicles. This coverage also pays for your legal defense if you are sued.

Property Damage (PD)
 Pays when an insured person is legally liable (responsible) for damage to the property of others caused by your vehicle and your operation of most non-owned vehicles. This coverage also pays for your legal defense costs if you are sued.

*The first two figures refer to bodily injury liability limits (which is required in New York) and the third figure refers to the property damage liability limit. For example, 25/50-10 means coverage up to $25,000 for each person injured in an accident, up to a maximum of $50,000 for the entire accident, and $10,000 worth of coverage for property damage.

Comprehensive and Collision
 Comprehensive and Collision coverage covers the cost to repair or replace your motorcycle if it is stolen or damaged in an accident, regardless of who is at fault. You select a deductible* for each coverage, and once the deductible is met, the insurance company pays for the remaining damage.

Note: A deductible is the amount you as the policy holder will pay.

Under Collision Coverage, your insurance company pays for damage to your vehicle when you collide with another vehicle or object.

Under Comprehensive Coverage, your insurance company pays for damage to your vehicle caused by an event other than a collision, such as fire, theft or vandalism.

Car Insurance Quote Form

Our new customers report savings of over $300-$700 annually.*

Do you want to save on your car insurance?

Find out now - get a quote!

Our satisfaction is saving you money.   We make it easy for you to save and keep money where it belongs . . . In your pocket for more important needs - You!

For faster service refer to a copy of current policy.
First time driver or new policy?  Have driving history for all drivers available.

GENERAL INFORMATION

Your Name:
Street Address:
City:
State: NEW YORK STATE ONLY!
Zip Code:
E-Mail (REQUIRED):
Phone:
Fax (optional):
 
Marital Status:
Single Married 		Homeowner?
Yes No
 
Currently Insured?
Yes No
(Current or prior insurance company?)

If Not Currently Insured
When did Cvg. End?
How long have you been
CONTINUOUSLY Insured?

Current Policy Term

Current Policy Expiration Date
Current Policy Premium
 
Current Limits of
Liability:		 $25k/50k $50k/100k
$100k/300k $250k/500k

DRIVER #1 INFORMATION
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Occupation: (If self-employed, please enter job description)
Highest Education:


In order to obtain all available DISCOUNTS, carriers run a low level insurance credit check. By providing Social Security # and Driver's License #, we can obtain the LOWEST RATE AVAILABLE!
Driver 1 Social
Security #:		 Driver 1 Driver's
License #:
State or Country
of License:

- IMPORTANT INFORMATION -
 To receive an accurate quote, you must provide information regarding the
approx. DATE and TYPE of any CLAIMS or TRAFFIC VIOLATIONS
within the last 39 MONTHS.
DATE CLAIM / TRAFFIC VIOLATION TYPE







Defensive Driving Course within last 3 years Check if yes

DRIVER #2 INFORMATION
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Occupation: (If self-employed, please enter job description)
Highest Education:


In order to obtain all available DISCOUNTS, carriers run a low level insurance credit check. By providing Social Security # and Driver's License #, we can obtain the LOWEST RATE AVAILABLE!
Driver 2 Social
Security #:		 Driver 2 Driver's
License #:
State or Country
of License:

- IMPORTANT INFORMATION -
 To receive an accurate quote, you must provide information regarding the
approx. DATE and TYPE of any CLAIMS or TRAFFIC VIOLATIONS
within the last 39 MONTHS.
DATE CLAIM / TRAFFIC VIOLATION TYPE







Defensive Driving Course within last 3 years Check if yes
VEHICLE #1 INFORMATION
 (if "Non-Owners", type "NON-OWNER" in "YEAR" Field)
Year of Vehicle: Make:
Model:
Sub Model: (EX,LX, etc.)
4 Wheel Drive: Y   N
Convertible: Y   N
# of Doors:
Est Annual Mileage: Usage:
Biz Use Detail
Miles to Work
Features:
Check all apply		 ABS Alarm System 1 Air Bag
Lojack Vin Etching 2 Air Bags
Daytime Lights      Auto Seat Belts
Vehicle ID/VIN

VEHICLE #1 COVERAGE:
MANDATORY COVERAGE  Please Select One Option:
($25k / 50k - $10k is the minimum allowed by law)
BI/GP - PD:
(See Definitions)		 $25k / 50k - $10k     $50k / 100k - $25k
$100k / 300k - $50k $250k / 500k - $100k
For  FULL COVERAGE  Please Select a Deductable Below:
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 

VEHICLE #2 INFORMATION
Year of Vehicle: Make:
Model:
Sub Model: (EX,LX, etc.)
4 Wheel Drive: Y   N
Convertible: Y   N
# of Doors:
Est Annual Mileage: Usage:
Biz Use Detail
Miles to Work
Features:
Check all apply		 ABS Alarm System 1 Air Bag
Lojack Vin Etching 2 Air Bags
Daytime Lights      Auto Seat Belts
Vehicle ID/VIN

VEHICLE #2 COVERAGES:
Comprehensive
& Collision:		 NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Comments or Remarks:
(List additional drivers, autos, etc. here)

Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!

ARM-Capacity's Policy on sharing information:

  1. We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  2. We will not distribute information to other parties other than for insurance underwriting purposes.
  3. *Average reported savings based on ARM of NY survey data through July 2005.

Please Send Me an Auto Quote NOW!

Click Button Below When Done

OR PRINT AND FAX THIS FORM TO
FAX: 212.937.3923

or Call:
888.ARMofNY - 888.276.6369
for an Express Phone Quote!

2008 (c) ARM-Capacity of New York, LLC., All rights reserved.  T: 888.276.6369  F: 212.937.3923