Auto & Home Fact Finding Form

  AUTO & HOME QUOTE FORM

Please complete and submit the information in the following form to request a preliminary quote.  Note: Items with * are required.

Complete Auto & Home Quote Form:

  *



  Vehicle Information:

Additional Information:  (check all that apply)

2DR
4DR
4x4
Pickup
ABS Brakes
Air Bags
Daytime Running Lamps
Car Alarm
Passive Seat Belts

Operators:











Homeowners (Please check all that apply):
Own
Rent

Mobile Home
Doublewide







NOTICE REQUIRED UNDER NEW YORK FAIR CREDIT REPORTING ACT

As part of our underwriting procedure, a consumer report may be requested to obtain information on an applicant's character, general reputation, personal characteristics and mode of living. Additionally, subsequent consumer reports may be requested on renewal as an update on your insurance application. Upon your written request, you will be informed whether or not a consumer report was requested, and if so, the name and address of the consumer-reporting agency to whom the request was made. You also have the right to inspect and receive a copy of this report by contacting the consumer-reporting agency. Under the New York Fair Credit Reporting Act we are required to obtain your authorization for requesting and investigative consumer report. Please indicate this authorization below.

**  Clicking the "Submit" Button or printing and signing this form, constitutes agreement by you, to allow if necessary, Permission to request an investigative consumer report on me.  **

*  This online quote will only provide you with the basics. For a more in depth quote they will need a copy of your current policy. Your insurance Rep. will call you and make those arrangements, or you can print this form and mail it, fax it, or walk it in. For Assistance feel free to call one of our representatives at 516-777-4800 - with any questions.  *

    

Fitzharris & Company

Brown & Brown of New York Inc. dba Fitzharris & Company
333 Earle Ovington Blvd
Suite 215
Uniondale, NY 11553

T: 1.516.944.2823