ALLNATION AGENCY,INC.
1777 Flatbush Avenue
Brooklyn NY 11210
Phone: 718-252-9251
Fax: 718-252-9356
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  WE OFFER
DISCOUNTS FOR:

• Defensive driving course
• Airbags & Auto seatbelts
• Anti-lock brakes
• Day-time running lights
• Anti-theft devices & VRS
• Etch glass
• Two or more vehicles
• Combination coverage
• Current insurance
• Careful driver & loss free   and deductible.
 
 
 


 
   

Questionnaire..

Thank you for taking the time to complete this questionnaire, any information you are not comfortable giving or is not applicable please leave out.

Please contv act us by phone, fax or email for any help. You can also download this questionnaire (in PDF format), fill out at your convenience and mail it to us.

• Click to download questionnaire. (new window)

Full Name:
Tel:
Home Work
Pager/Cell:
Email:
Address:
Own Rent
Prior Address:
How Long?
 Yea(s) Months(s)
Job Title:
How Long?
 Year(s) Month(s)
Employer Name:
Employer Address:
Marital Status:
 Married Single
Date Of Birth:
State License:
License #:
Social Security#:
Spouse/Other Name:
Date Of Birth:
State License:
How Long?
 Year(s) Month(s)
License #:
Social Security#:
Driving Record:
Credit History:
Year of Vehicle:
Make:
Model:
Body/Class:
Vin. #:
Miles on Meter:
Yearly Miles:
Miles to Work:
Discount/Credit:
 Airbags
ABS
DRL
P/Alarm
LoJack
Etched Glass
DDC
Prior Insurance Company:
Auto Home
Policy#:
How Long?
 Year(s) Month(s)
Annual/Semi. Premium $:
Payment $:
 Monthly
Best Quote $:
Coverage $:
Vehicle Use:
 Private Commercial
Bank/Finance Company:
Address:
 
I Hereby Authorized Leo Agency & Brokerage to be my broker

Please type your full name (All Capital)
   
 
Contact us TODAY for a FREE Estimate!
Call 718-252-1170, Fax 718-252-9356
Email: allnationagency@aol.com
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