Sodus, NY 315-483-6431
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Newark, NY 315-331-7925
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Seneca Falls, NY 315-568-8100
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Auto Quote Form
This information is required:
Primary Insured (your name)
*
Primary Insured Telephone Number
*
Primary Insured Address
*
This information is optional - we can contact you for the details if you do not wish to fill out all sections below:
Date of Birth
Driver License Number/State
Social Security Number
Any tickets within past 5 years?
Yes
No
DWI or suspended license within past 5 years?
Yes
No
Vehicle Use
Pleasure
Commute
Business
Marital Status
Married
Single
Home Quote
The following information is required for your quote:
Name(s) (list all owners)
*
Best Number To Reach You
*
Alternate Telephone Number
Closing Date (If not currently)
*
Date You Need Quote
*
Current Address
*
New Address (to be insured)
*
The following info is optional but would surely help us provide an accurate quote...
Date of Birth
Social Security Number
Construction
Frame
Brick
Modular
Mobile
Market/Assessed Value
Number of Families/Apartments
How much money will you need to replace your personal property?
Heating Fuel Type (i.e. - electric, gas, natural gas, LP, oil, coal, wood)
Number of Stories?
How many feet to nearest hydrant?
How many miles to nearest fire department?
Any smokers living in premise?
Yes
No
Are there smoke detectors?
Yes
No
Is there a centrally monitored security alarm?
Yes
No
If there are animals, please list each breed and describe below:
If there is a pool,please describe above/below ground, fenced/un-fenced, diving board, slide etc...
If you are currently insured please list company:
Insurance Expiration Date:
Claims within the last 10 years?
Yes
No
Please list dates of any updates or improvements of the following:
Roof
Electric
Plumbing
Heating
Siding/Painted
Please select the following features in your residence:
Kitchen
Dining Room
Living Room
Master Bedroom
Additional Bedrooms
Full Bathroom
1/2 Bathroom
Finished Basement
Unfinished Basement
Garage
Detached Structures
Fireplace/Stove
Central Air
Porch
Laundry
Wood Siding
Aluminum Siding
Vinyl Siding
Square feet of porches/decks
Please list additional policies you have with Nichols Financial
