Glens Falls, NY

Car Insurance

Automobile Insurance: If you own or lease a car, you'll find dependable service, competitive rates and attractive coverage options with our auto insurance packages. When you need to make a claim, we are committed to the highest service standards.

We offer a range of coverages, bill plans, and service options that take the hassle out of auto insurance.

We can help you save money with driver training, college kids away at school and multiple cars. Read our Auto Tips for more information.

Click here for information on Business Vehicles.

Fill out the form below, and we'd be happy to give you a quote on your Automobile Insurance. Or give us a call at 798-0057.
Name:
Company:
Address:
City:
State:
ZIP:
Phone Day:
Phone Evening:
Email:
How do you prefer to be contacted?
Day Phone Evening Phone Email

Present Insurance Company:

Expiration Date:

Annual Premium:
$

Vehicles
Vehicle Year:
Make:
Model:
Vehicle ID#:
Miles to work:

If only one vehicle skip to Drivers
Second Vehicle Year:
Second Vehicle Make:
Second Vehicle Model:
Second Vehicle Vehicle ID#:
Miles to work:

Third Vehicle Year:
Third Vehicle Make:
Third Vehicle Model:
Third Vehicle Vehicle ID#:
Miles to work:

Drivers
Driver Name:
DOB:
Married/Single: Married Single:
Drivers License#:
If not NY, please specify:
Social Security#:
Percentage of use by driver
Driving History:
Has driver had his/her license suspended or revoked? Yes No
If yes, please explain when and why:


List any accidents or moving violations in the past 5 years.
Please list date and type of incident:


List all fire, theft, glass and/or vandalism losses in the past 3 years:

If only one driver skip to end
Second Driver Name:
Second Driver DOB:
Second Driver Married/Single: Married Single:
Second Drivers License#:
If not NY, please specify:
Social Security#:
Percentage of use by 2nd driver
Driving History for Second Driver:
Has driver had his/her license suspended or revoked? Yes No
If yes, please explain when and why:


List any accidents or moving violations in the past 5 years.
Please list date and type of incident:

Third Driver Name:
Third Driver DOB:
Third Driver Married/Single: Married Single:
Third Drivers License#:
If not NY, please specify:
Social Security#:
Percentage of use by 3rd driver
Driving History for Third Driver:
Has driver had his/her license suspended or revoked? Yes No
If yes, please explain when and why:


List any accidents or moving violations in the past 5 years.
Please list date and type of incident:

Comments? Additional Vehicles or Drivers?



| Who We Are | Services | Auto | Home | Boats | Business | Cycle and ATVs |
| Life & Financial | Tips | Quotes | Links | Contact Us | Home |

DeMattos Insurance Agency, Inc.
P.O. Box 2022
158 Ridge Street
Glens Falls, NY 12801
518.798.0057
800.734.0057
Fax: 518.798.1684

tonydemo@demattosinsurance.com