Commercial Insurance

Driver: Complete the following information about yourself.
First Name*    
Last Name*    
Address *    
Company name    
State    
Zip Code    
Email *    
City    
DOB (mm/dd/yy)
Phone# *  
License#
License Status
List Tickets, Accidents, and Comprehensive Losses
 
Financial and Insurance Background: For a more accurate quote, complete the following information about your credit history and prior insurance.
Occupation
Credit Status
Housing    
Years at Address    
Insurance Status
Your prior insurance was in force for how long?  
Have you taken a Defensive Driving Course
Policy Information: Complete the following information about the insurance policy that you are interested in.
Vehicle
Liability    
DeduCTible    
Glass Coverage    
 
Vehicle# 1: Complete the following information about the insurance policy that you are interested in.
Year    
Make  
Model  
Doors    
4x4    
Gross Weight    
Value of Vehicle    
Vehicle User For
VIN Number
If you have more than one vehicle & driver please describe here:
 
Disclaimer Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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Quick ContaCTs

72-32 Broadway suite # 402 Jackson Heights, NY 11372.

Tel: 1877-GO1-Linx
718-505-1751

E-Mail:Sales@linxinsurance.com



 
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