ONLINE AUTO QUOTE

To receive your online quote, simply fill out the form below and submit it. We will contact you with a quote and answers to any questions you may have.



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Primary Driver’s Name:
Date of birth:
   Today’s date:
Street:
City:
  State:   Zip:
Home Phone:
   Work Phone:
Fax Number:
   E-Mail Address:

Car To Be Insured:
If you have more than one car, please list info in the "Questions Or Comments" section at the bottom of this form.
Year:
   Make:
   Model:
Value:
   Annual Mileage:

Is the car to be garaged?   Yes   No

List any traffic violations, accidents and the dates:

Complete if you are married:
Spouse’s name:
   Spouse’s date of birth:
List any of your spouse’s traffic violations, accidents and the dates:

Complete for children of driving age living at home:
Number of children 16-25 years old:

List any of your children’s traffic violations, accidents and the dates:

Current insurance information:
How many regular use vehicles do you own?
List year make and model of each vehicle:

What is your current amount of liability coverage? 
What is your current amount of uninsured motorist coverage?

Questions or comments:

Click the submit button to submit this form or the reset button
to clear the information and start over.
CONTACT INFORMATION
Northeast Classic Auto Insurance
P.O. Box 287 • 40 Georges Lane
Monroe, CT 06468
Toll Free: 1-800-866-6440
Phone: 203-459-9789
Fax: 203-459-9791
E-Mail us at classiccarinsurance@specialinterest.com
www.classiccarinsurance.com
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