Cafarelli Insurance Agency Ltd

Tel: 631.543.6363 Fax:631.543.4891
1030 Jericho Tpke. Smithtown, NY 11787

Cafarelli Realty

FORMS

Homeowner's Insurance

Professional Liability

Financial Services

Automobile Application

Name (s)

Address

Phone Number Please enter your phone number

SS Number

Please enter your social security number

Prior Carrier Please enter your previous carrier

Drivers

Date(s) of Birth Please indicate the date of birth of each driver

Please indicate the date of birth of first driver

Please indicate the date of birth of second driver

Please indicate the date of birth of third driver

Please indicate the date of birth of fourth driver

License Number(s) Please enter the license number for each driver

Please enter the license number for first driver

Please enter the license number for second driver

Please enter the license number for third driver

Please enter the license number for fourth driver

Vehicles - Make, Model and VIN # Please indicate make, model and VIN number for each vehicle

Please indicate make, model and VIN number for first vehicle

Please indicate make, model and VIN number for second vehicle

Please indicate make, model and VIN number for third vehicle

Please indicate make, model and VIN number for fourth vehicle

Coverages

Bodily Injury - $ Please indicate value of bodily injury coverage

Property Damage - $ Please indicate value of property damage coverage

Medical Payments - $ Please indicate value of medical payments coverage

SUM - $

PIP - $

Comp and Collision Deductibles Please indicate the comp and collision deductibles for each vehicle

Please indicate the comp and collision deductible for first vehicle

Please indicate the comp and collision deductible for second vehicle

Please indicate the comp and collision deductible for third vehicle

Please indicate the comp and collision deductible for fourth vehicle

Lienholder / Loss Payee Please indicate the lienholder / loss payee for each vehicle

Please indicate the lienholder / loss payee for first vehicle

Please indicate the lienholder / loss payee for second vehicle

Please indicate the lienholder / loss payee for third vehicle

Please indicate the lienholder / loss payee for fourth vehicle

Prior Insurance - Premium and Effective Date Please indicate premium and effective date from your prior insurance

Referred By Please indicate if you were referred by someone

Please enter your name:

Please enter your email address:

Serving the following towns of the Northshore and Southshore of Long Island:

Nassau County -Baldwin, Garden City, Levittown, Valley Stream, Manhasset, New Hyde Park, Port Washington, Cold Spring Harbor, Glen Cove, Great Neck, Lloyd Harbor, Muttontown, Hicksville, Oyster Bay, Old Brookville, Roslyn, Massapequa, Wantagh, Bethpage, Seaford, Syosset, Woodbury and the surrounding areas.

Suffolk County - Babylon, Lindenhurst, Bayshore, Bohemia, Hauppauge, Melville, Shirley, Mastic, West Islip, East Islip, Oakdale, Sayville, Bayport, Huntington, Northport, Stonybrook, Kings Point, Smithtown, Saint James, Port Jefferson, Setauket, Mount Sinai, Miller Place, Center Moriches, Selden, Holbrook, Ronkonkoma, Medford and the surrounding areas.

Also serving the Five Boroughs and Tri State Area.

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