NY auto insurance from the Lang Agency, LLC
NY auto insurance from the Lang Agency of New York
NY auto insurance from The Lang Agency LLC
NY home  insurance quotes
ny car insurance quotes from The Lang Agency LLC

Come Visit Us in Middletown, NY!
the Lang Agency, LLC
The Lang Agency, LLC
22 County Route 78,
Suite 2
Middletown, NY 10940
(Click for Office Map/Directions)
 
E-Mail:
greg@thelangagency.com

Local Phone:
845-342-5264
(845-342-LANG)

Fax:
845-342-5263


Order Our Free Money Saving Report:
The Lang Agency LLC offers online auto and home insurance quotes Get Our Free Report!

"12 Ways to Save Money on Your Auto Insurance"
Your Name
Your Email

Visit Our Agency's Other On-Line Quote Forms and Start Saving!
 
Auto Insurance Quote

Home Insurance Quote

Motorcyle Ins. Quote

R.V. Insurance Quote

Classic Car Quote

Boat Insurance Quote

Renters Insurance Quote

Condo Insurance Quote

Commercial Auto Quote

Flood Insurance Quote

Personal Umbrella Quote

Life Insurance Quote

Defensive Driver Program

About Our Agency

Office Map/Directions

Policy Service Request

Privacy Notice

The Lang Agency LLC - new york insurance agency
 
On-Line Boat & Jet Ski
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
State: (Must be New York)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
Primary Insured's Occupation:
 
Marital Status:
Single Married
Homeowner?
Yes No
 
Boat Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
Is this Boat Co-owned?
(If yes, list all owners names)


OPERATOR INFORMATION #1
Name: Birthdate:
Sex (M/F): # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Number of Years
Boating Experience:


OPERATOR INFORMATION #2 (if none, leave blank)
Name: Birthdate:
Sex: # Years U.S.
 Licensing:
Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:
Number & Type of Accidents last 3 years: Number & Type of MINOR violations last 3 years:
Number & Type of MAJOR violations last 3 years: Number of Years
Boating Experience:


VESSEL & UNDERWRITING INFORMATION
Year of Boat: Make & Model
(be specific):
 
Boat Length: Hull Type
(wood, Metal,
fiberglass, etc):
 
Max. Speed
(in MPH):
Market Value: $
 
Engine Make: Engine Type:
(Inboard, I/O, Jet)
 
Engine Horse
Power:
Fuel Type:
(Gas, Diesel, etc.)
 
Trailer Cov.
Needed?
Yes No Yr./Make/Model
of Trailer:
 
Trailer Value: $ Where is boat
moored or stored?
 
Describe waters
boat taken on?
Describe boat
general usage?
(fishing, ski, etc.)


VESSEL COVERAGES:
Limits of
Liability:
$15/30 BI / 10 PD $25/50 BI / 15 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD
$250/500 BI / 100 PD
 
Hull Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible
 
Water Ski
Medical Coverage?
Yes No   Uninsured
  Motorists Cov.?
Yes No
 
Comments or Remarks:
(List additional drivers,
special coverages, etc. here)


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

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me a Boat Quote NOW!


Click Button Below When Done

Please Click Only Once . . . May take up to 30 seconds!

NY auto and homeowners insurance
Helpful terms used to find us in most major search engines: New York auto insurance, NY auto insurance, New York home insurance,
NY home insurance, New York life insurance, NY life insurance, low cost New York car insurance, discount new york homeowners insurance,
fast and free NY term life insurance quote, discount new york personal and business insurance.

Web Site Design © 2012, Insurance Web Sales