Auto Insurance Questionnaire

AUTO INSURANCE
QUESTIONNAIRE

Drivers:

You Name:

Date of Birth:

Social Security Number:

Drivers License Number:

Married: (Y/N)

Spouse information (required if married)

Spouse Name:

Spouse Date of Birth:

Social Security Number:

Drivers License Number:

Home address:

Vehicles:

Year:

Make:

Model:

Vin#:

Use (pleasure/work):

Number of miles to work one way:

Anti-Lock Brakes: (Y/N)

Alarm: (Y/N)

Number of Air Bags:

Day Running Lights: (Y/N)

Year:

Make:

Model:

Vin#:

Use (pleasure/work):

Number of miles to work one way:

Anti-Lock Brakes: (Y/N)

Alarm: (Y/N)

Number of Air Bags:

Day Running Lights: (Y/N)

Coverages:

Bodily Injury: Each Person

Each Accident:

Property Damage:

Uninsured Motorists:

Comprehensive Deductible:

Full Glass: (Y/N)

Collision Deductible:

Do you have insurance now?

Please attach a copy of your current policy for comparison

Fax/mail/email form to:

Graf Agency Inc.

1573 NY Avenue

Huntington Sta., NY 11746

Phone 631 423 2233

Fax 631 423 2619

Email marygraf@grafinsurance.com

Mary Graf has provided our small business with the knowledge, tools, and expertise to make informed decisions regarding our insurance investments. She is a warm and professional person who is highly motivated to do the absolute best for her clients and community.

Brian Botticelli , Botticelli Prints Inc. Huntington, NY
Mary has been our insurance broker for many years. Her extensive knowledge of the companies and product offerings is critical to securing the best coverage for us. Her ability to ask the right questions, delve into the most relevant information and discern our requirements has forged a strong working relationship. Personally delightful and professionally efficient, Mary and her agency staff always provide top-shelf service!

Fritzi Gros-Daillon , Anson Environmental Corp. Transitions USA Inc.
When I think of insurance, I think “Graf Agency.” I first joined our family business in 1984 and when I was introduced to Ken Graf, I soon realized why our family did business with his family.

Over the years, Mary Graf has continued the family tradition of unmatched service, responsiveness and attention to detail. I know I can always depend on Mary to possess the knowledge, do the research and advise me on the best products for our business and my personal needs.

The peace of mind that this provides is priceless.

Joseph Fusaro , Green Energy Solutions AMJ Building Corp. Huntington, NY
As a Business Management Consultant with high-end clients who demand excellence, I only work with Mary from the Graf Agency for all my insurance needs.

Mary’s response time, care and attention to my requests are always impeccable. Not only does she know her industry very well and provide the best packages, but she also takes the time to research the most cost-effective ways to make sure I am always offering my clients the very best!

Evan Antonini, EHM Group, LLC Bookkeeping & Controllership Services New York, NY

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