Bakos Agency Automobile Quote:

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Name
Address
City
State
Phone
E-mail address
Maritial Status
Single Married

Driver Information

Date of Birth
License Number
Occupation

Current Insurance Company & expiration Date

Current Insurance Company
expiration Date
Defensive Driver,Driver Education, Good Student option Yes No

If yes - Name, Date, Description:
Any of the above drivers, had any accident or/& convictions Yes No

If yes - Name, Date, Description:
Any of the above driver(s), had recieved a ticket in the last 39 months? Yes No

If yes - Name, Date, Description:
Any of the above driver(s), got arrested for DWI? Yes No

If yes - Name, Date, Description:
Any of the above driver(s), have or had a prior 6 month insurance? Yes No
Company
Effective Date

Vehical Information

Year
Make
VIN #
No Air Bag
1 Air Bag
Miles on Car
ABS
DRL
Alarm System
Is vehicle leased or Loan Yes No
Drive for
work Pleasure
if for work,how many miles one way
Is this vehicle used for business? Yes No

Coverage Limits and Deductibles:

Liability Property Damage Supplemental Uninsured Motorist Personal Injury Protection OBEL
Medical Payment Comprehensive Full Glass Collision Renatal Reimbursement Towing

Additional Driver 1

Date of Birth
License Number
Occupation

Current Insurance Company & expiration Date

Current Insurance Company
expiration Date
Defensive Driver,Driver Education, Good Student option Yes No

If yes - Name, Date, Description:
Any of the above drivers, had any accident or/& convictions Yes No

If yes - Name, Date, Description:
Any of the above driver(s), had recieved a ticket in the last 39 months? Yes No

If yes - Name, Date, Description:
Any of the above driver(s), got arrested for DWI? Yes No

If yes - Name, Date, Description:
Any of the above driver(s), have or had a prior 6 month insurance? Yes No
Company
Effective Date
+ Add Additional Driver

Additional Vehical 1

Year
Make
VIN #
No Air Bag
1 Air Bag
Miles on Car
ABS
DRL
Alarm System
Is vehicle leased or Loan Yes No
Drive for
work Pleasure
if for work,how many miles one way
Is rhis vehicle used for business? Yes No

Coverage Limits and Deductibles:

Liability Property Damage Supplemental Uninsured Motorist Personal Injury Protection OBEL
Medical Payment Comprehensive Full Glass Collision Renatal Reimbursement Towing
+ Add Additional Vehicle
Additional Comments

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1099 French Rd.   I    Cheektowaga, NY 14227   I    Phone: (716) 668-5700   I    Fax : (716) 668-5840