Petruzelo Insurance Agency, Inc. - Get A Quote

For a FREE, No-Obligation Quote,
fill in the form below and a representative will contact you.

For the most accurate quote, please provide us with complete information.

	Automobile

Note: Required fields are marked with an asterisk (*)

Personal Information Name*:
Current Address*:
City*:
State:
Zip*:

Home Phone*: - -

Work Phone: - -
E-mail*:

Date of Birth*:

Date of Birth*:
Present Auto Insurance Company:
Date Auto Insurance Expires:
Do you own or rent your home?:
How long at your present address*:

Prior Address*:
Prior City*:
Prior State*:
Prior Zip*:

Prior Address:
Prior City:
Prior State*:
Prior Zip:

Are You a AAA Member?:
How Did You Hear About Our Agency?:

Who*:

Other*:

Automobiles Details

	Year	Make	Model	Miles to Work (One Way)	Annual Millage
Car #1
Vehicle ID#
Car #2
Vehicle ID#
Car #3
Vehicle ID#
Car #4
Vehicle ID#

Driver #1 Driver Name:
Driver License #:
Social Security #: - -
Date of Birth:
Gender:
Marital Status:
Occupation:
Education Level:
Number of Tickets in the Last 5 Years:

Explanation of Tickets:
Number of Accidents/Violations in the Last 5 Year:

Explanation of Accidents/Violations:

For Drivers Age 16-20 Drivers Training Classes:
Student G.P.A (Grade Point Average):
Is Student living over 100 miles away from home without a vehicle:

Percent of Use:

Car #1:
Car #2:
Car #3:
Car #4:

For Drivers Age 55+
55 Alive Course:
Date: / /

Driver #2 Driver Name:
Driver License #:
Social Security #: - -
Date of Birth:
Gender:
Marital Status:
Occupation:
Education Level:
Number of Tickets in the Last 5 Years:

Explanation of Tickets:
Number of Accidents/Violations in the Last 5 Year:

Explanation of Accidents/Violations:

For Drivers Age 55+
55 Alive Course:
Date: / /

Driver #3 Driver Name:
Driver License #:
Social Security #: - -
Date of Birth:
Gender:
Marital Status:
Occupation:
Education Level:
Number of Tickets in the Last 5 Years:

Explanation of Tickets:
Number of Accidents/Violations in the Last 5 Year:

Explanation of Accidents/Violations:

For Drivers Age 55+
55 Alive Course:
Date: / /

Driver #4 Driver Name:
Driver License #:
Social Security #: - -
Date of Birth:
Gender:
Marital Status:
Occupation:
Education Level:
Number of Tickets in the Last 5 Years:

Explanation of Tickets:
Number of Accidents/Violations in the Last 5 Year:

Explanation of Accidents/Violations:

For Drivers Age 55+
55 Alive Course:
Date: / /

Liability Limit for All Cars Choose either Bodily Injury & Property Damage OR Single Limit
Bodily Injury:
Property Damage:
Single Limit:
BRB or Medical Payments:
UM/UIM (Will Match Liability Limits)
Full Glass:

Car #	Deductible Comprehensive	Deductible Collision	Towing	Loss of Use/Rental Reimbursement
Car #1	100 \| 250 \| 500	100 \| 250 \| 500
Car #2	100 \| 250 \| 500	100 \| 250 \| 500
Car #3	100 \| 250 \| 500	100 \| 250 \| 500
Car #4	100 \| 250 \| 500	100 \| 250 \| 500

Security & Privacy
This site uses Secure SocketsLayer (SSL) encryption for all customer
data and has been authenticated by Verisign.

View Privacy Policy

The submission of this form does not obligate you to purchase. This is for quoting purposes only and in no way provides, effects, or binds any insurance coverage.

We are licensed in the following states/provinces:
Connecticut, Maine, Massachusetts, New Hampshire, New York, Pennsylvania, Rhode Island, and Vermont

© 2009 Petruzelo Insurance Agency.   All rights reserved.
4 Research Parkway  | PO Box 5050  |  Wallingford, CT 06492-7550
Call Us Toll Free: 1-866-479-3327 | Fax: 203-269-7588
insure@petruzelo.com

Privacy Notice  |  Sitemap

Personal Business

Who We Are Alliances Carriers Testimonials