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Joshua J. Stephen Associates Insurance Agency
516-481-5010- NY
516-203-7168- NY Fax
954-323-4136- FL
954-323-4052- FL Fax
Please tell us a little about yourself
Name
*
First
Last
Co-Applicant Name (If applicable)
*
First
Last
Email
*
Co-Applicant Email
*
Phone Number
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-
-
Co-Applicant Phone Number
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-
-
Date of Birth
*
Co-Applicant Date of Birth
*
Occupation
*
Driver's License Number
*
Years Licensed
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Less than 1 Year
Between 1 and 3 Years
3 Years or more
Co-Applicant Occupation
*
Co-Applicant Driver's License Number
*
Years Licensed (Co-Applicant)
*
Less than 1 Year
Between 1 and 3 Years
3 Years or More
Please describe any accidents or claims within last 5 years
*
Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Please list info of any other household members below
*
Now please tell us a little about your vehicle
Primary Use of Vehicle
*
Pleasure
Commute
Business / Commercial
Year
*
Make
*
Model
*
VIN Number
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Garaging Address (If different than above)
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Line 1
Line 2
City
State
Zip Code
Country
Vehicle Discounts (Check all that apply)
*
Anti Lock Brakes (ABS)
Anti Theft
Passive Restraint
Daytime Running Lights
Help us help you. Please upload the following documents if available:
Previous Policy Declarations Page
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