How to Contact Us:

Marlin Insurance Agency
1138 William Floyd Parkway
P.O. Box 434
Shirley, NY 11967-0434

Tel: (631) 281-6200
Fax: (631) 399-7905
Email: info@marlinagency.com

Auto Insurance Quote Request

Please provide some basic information so we may begin to provide a rate quote.

We will contact you for any additional information that we need to complete your quote. Please note that fields with asterisks are required.


I. Number of Drivers

*No. of Drivers:

Driver #1
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driver:

Driver Training:

Driver #1
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #2
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:

Driver #1
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #2
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #3
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:

Driver #1
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #2
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #3
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #4
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:

Driver #1
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #2
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #3
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #4
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:


Driver #5
Name:

Address:

City:

State:
Zip Code:

Phone:

D.O.B.:
mm/dd/yyyy

License Number:

Years Licensed:

Accidents in Past 5 Yrs.:

Violations in Past 5 Yrs.:

Distance to Work:

Defensive Driving:

Driver Training:



I. Number of Vehicles

*No. of Vehicles:

Vehicle #1
Year:

Make:

Model:

VIN #:

Discounts:

Ctrl + Click for multiple selections.

Operator:

Vehicle #1
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:


Vehicle #2
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:

Vehicle #1
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:


Vehicle #2
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:


Vehicle #3
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:

Vehicle #1
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:


Vehicle #2
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:


Vehicle #3
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:


Vehicle #4
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:

Vehicle #1
Year:

Make:

Model:

VIN #:

Discounts:

Ctrl + Click for multiple selections.

Operator:


Vehicle #2
Year:

Make:

Model:

VIN #:

Discounts:

Ctrl + Click for multiple selections.

Operator:


Vehicle #3
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:


Vehicle #4
Year:

Make:

Model:

VIN #:

Discounts:

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Operator:


Vehicle #5
Year:

Make:

Model:

VIN #:

Discounts:

Ctrl + Click for multiple selections.

Operator:





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Useful Links:
F.E.M.A
www.fema.gov
NYS Insurance Dept.
www.ins.state.ny.us
NYS Dept. Motor Vehicles
www.nydmv.state.ny.us
Kelly Blue Book
www.kbb.com
Wedding Insurance
protectmywedding.com

DISCLAIMER
To our valued clients; please note that no new insurance coverage or existing policy endorsements may be bound with the use of this Web site. Please contact our Agency directly to complete those requests.