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YOUR NAME
First Name Middle Initial  
Last Name Suffix   
Email Phone  
ADDRESS INFORMATION
Street_Address City  
State Zip Code  
Residence_Type
ADDITIONAL INFORMATION
Have you changes residences in the past 60 days? Yes   No   
Are all vehicles for this quote model year 1981 or newer? Yes   No    
Do you have 5 or more vehicles to insure? Yes   No
Have you and/or spouse had continuous liability insurance for the past 6 months with no more than a 30 day lapse? Yes   No
VEHICLE INFORMATION
VEHICLE 1 VEHICLE 2
Vehicle Information Number (VIN) Vehicle Information Number (VIN)
If you don't know your Vehicle Identification Number (VIN), you may leave this field blank
Year
Year
Make Make
Model Model
Body Style Body Style
ADDITIONAL VEHICLE INFORMATION
Zip Code where vehicle kept Zip Code where vehicle kept
Primary Vehicle Use Primary Vehicle Use
Snowplow attached? Yes  No Snowplow attached? Yes  No
Anti-theft system/alarm Yes  No Anti-theft system/alarm Yes  No
Passive Restraint Passive Restraint
Liability Limits Liability Limits

Driver #1 Driver #2 Driver #3
Does this driver operate the listed vehicle(s) less than 50% of the time? Yes  No Yes  No Yes  No
Has this driver had a foreign driver's license in the last 12 months? Yes  No Yes  No Yes  No
Accidents, violations or comprehensive claims in the last 35 months? Yes  No Yes  No Yes  No
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SKYLINE SERVICES
Stateline Plaza Route 858, Little Meadows, PA
PA (570) 623-3000  NY (607) 625-4788

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