Katz & Unterreiner Inc. Ins.
               1045 Park Street, Parkmall                                                            1460 Rt 9                              E-Mail:kuinc@aol.com
                         Peekskill, NY 10566                                                         Wappingers Fls, NY 12590

     (914)737-0021    fax (914)737-5801                   (845)297-0111    fax (845)297-2364
     



Welcome to our new site. Here you will find forms and tools you can use to make searching for insurance easier. We are still in the process of adding functionality, but take a look around and use the Contact Us link to let us know what you think. Thank You! 

©2007, Katz & Unterreiner Inc. Ins. All rights reserved.
 
   

Automobile Insurance Quote Request

This process will allow you to request a quote for up to 4 vehicles and 4 drivers.
Please remember that the more information provided, the more accurate the quote we provide will be. The fields marked in red are required.

This is some information you should have available to complete the form:

   1) Year/Make/Model or VIN for each vehicle
   2) Name/Date of Birth for each driver
   3) Accidents/Violations within the last 36 months

Referrer's Name:
Name:   Phone:  
Address:   E-Mail:
City:   State:   SS#:  
Spouse: Spouse SS#
Full Glass Coverage Desired:Yes  No 
Single/Married:Married  Single 
Children:Yes  No   Driving: Yes No  Age(s):

Driver Information
Driver #1

 
DOB:
 License#
 Occupation: Employer:
Defensive Driver TrainingYes No
 
Driver #2
DOB:
 License#
 Occupation: Employer:
Defensive Driver TrainingYes No  
 
Driver #3  
DOB:
 License#
 Occupation: Employer:
Defensive Driver TrainingYes No  
 
Driver #4      
DOB:
 License#:
 Occupation: Employer:
Defensive Driver TrainingYes No    
 
Tickets in the last 39 months?  Yes No

DWI in the last 10 years?  Yes No

Prior 6 month insurance? Yes No    Company: 
Effective Dates:


Vehicle Information
Vehicle #1
Year Make Model VIN#
Miles Driven To Work  Air Bag Yes No,  1 or 2
ABS:  YesNo DRL: YesNo Alarm:YesNo Type:

Antilock Braking System     Daytime Running Lights 
      
Vehicle #2      
Year Make Model VIN#
Miles Driven To Work Air Bag Yes No, 1  or 2  
ABS: YesNo DRL:  YesNo Alarm:YesNo Type:
Antilock Braking System      Daytime Running Lights

     
Vehicle #3
Year Make Model VIN#
Miles Driven To Work Air Bag Yes No, 1  or 2
ABS:Yes No DRL: YesNo Alarm: YesNo Type:
Antilock Braking System      Daytime Running Lights
     
Vehicle #4
Year Make Model VIN#
Miles Driven To Work Air Bag Yes No, 1  or 2  
ABS:Yes No DRL: YesNo Alarm:  YesNo Type:
Antilock Braking System      Daytime Running Lights

Coverage Desired

Vehicle #1

Liability:

 Collision Deductible: Comprehensive Deductible:

Vehicle #2

Liability:

 Collision Deductible: Comprehensive Deductible:

Vehicle #3

Liability:

 Collision Deductible: Comprehensive Deductible:

Vehicle #4

Liability:

 Collision Deductible: Comprehensive Deductible:
                                

 

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