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TANNER-IBBOTSON, Inc.

1109 Commons Avenue      Cortland, NY 13045    607.756.7531

Your Local Independent
Insurance Agency

Auto Insurance Contact Form

 

Let us provide a quote for you

We have several companies to work with. The more information we receive, the better job we will be able to do for you. Please complete the following questionnaire and we will get back to you with a quote. Be sure to complete all sections.

 

 

 

 

 


  Please fill out the contact information below:  
  First Name*
  Last Name*
Company
Address
  City  
  State  
  ZIP  
Country
Home Phone
  Work Phone  
Fax
  E-Mail *  
       
Garaging Address (if different)
   
Address  
  City
  State  
  ZIP  
Country  
       
Vehicle Rating Information
       
Year
  Make  
  Model  
  Principal Driver  
  Use Type   If "Use Type" is Commute: Miles one-way    
Days per Week 
       
  # of Unlicensed Household Members under 19    
  Has the Applicant resided at the current residence for less than 3 years?   If yes, Prior address:   
 
  Has any Driver ever been suspended or revoked?  
  Has any Driver with Physical  Impairments or ever been treated for mental condition, heart ailment, epilepsy, or diabetes?  
  Has any Driver ever been in assigned risk plan or had any insurance declined, cancelled, or non-renewed within last 3 years?  
Additional Vehicle Information
  Has any Vehicle been modified or specially equipped?  
  Has any Vehicle have any existing damage?  
  Has any Vehicle kept at college?  
  Is any Vehicle parked on the street?  
       
Additional Insurance Information
  Does the Applicant have Boat Insurance?  
Does the Applicant have Commercial Insurance?
  Does the Applicant have Health Insurance?  
  Does the Applicant have Inland Marine Insurance?  
  Does the Applicant have Life Insurance?  
  Does the Applicant have Motorcycle Insurance?  
  Does the Applicant have Recreational Vehicle Insurance?  
Does the Applicant have Umbrella Insurance?





 
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Copyright © 2011-15 Tanner-Ibbotson, Inc. All Rights Reserved.
1109 Commons Ave., Cortland, NY 13045
Phone: (607) 756-7531 Fax: (607) 753-3050
Inquire@TannerIbbotson.com

 

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