Brokerages/Agencies:

 NY, New York
 NJ, New Jersey
  CT, Connecticut

Coming Soon:
  PA, Pennsylvania
 

Contact Us. . .
 To find out more
about advertising  your business contact our Sales & Marketing Department at:

1-800-753-9138

 

 
 
 

 

 
 
 Win $1,000.00 towards your Insurance Premium!
 Policyholders, entering is absolutely FREE!
 Each submission increases your chances to win!
Businesses / Advertisers
 Get Listed 6 Months FREE!
Brokerages | Driving Schools | Body Shops
 
      

 
 

$1,000 Dollars! Go ahead! Now's Your Chance . . . Submitting Your Entry  is Absolutely FREE!
Take a moment to complete the Submission Form found right below.

  Eligibility
1. You must be at least 18 years of age and a U.S. resident to participate.
2. You must have a valid drivers license and an active Auto Insurance Policy to participate.
 

     

First Name:
 
Last Name:

 
Date of Birth:  
     
Driver's License Number
 
State


 
 
 
Address:  (optional)
 
City

 
 State
 
 
Zipcode

 
Telephone Number:    Home   Work
--   Extension:
 
 
E-Mail Address:
 
 
Comments / Remarks
:




 
Brokerage / Agency Information


 
Brokerage / Agency on ID Cards: Insurance Company on ID Cards
 
Telephone Number:   Broker / Agent Name:
--
Policy Number and 3 Digit Company Code:      
 
Brokerage / Agency Address on ID Cards:
Policy Premium:
6 Month Policy
12 Month Policy 
 
City:

 
 State:
 
 
 Zipcode

 
 
 
 

Is the above listed Brokerage/Agency listed through the State Directory?
Yes    No    Not Certain 
 
 
Vehicle(s) Being Insured
 
Make:
Model:
Year:

 
 
Current Coverage on the Above Vehicle
  
Liability Only:     Full Coverage:
 
 
 

If randomly selected, Brokerage/Agency & Insurance Company Information will be confirmed prior to awarding $1,000 Dollars towards any balance of  your current Auto Insurance Policy.
 

  (Note: Invalid Information will disqualify your entry.)

 
 
 
 

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