Galaxy Insurance Service, Inc.

"We Go Above And Beyond To Find You The Best Rates In Town!"

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posted by Anonymous on Wed, 07/13/2011 - 11:30

Galaxy Insurance Service Inc
1001 East Pacific Coast Highway Suite 107
Long Beach, CA 90806
Phone (562) 591-8901, Fax (562) 591-3901
http://www.galaxyinsurance.com/
csr@galaxyinsurance.com
CA Lic #0D44460

* = required

Effective Date *

Month

Day

Year

Contact Info

Applicant Name *

Home Phone *

Work Phone

Fax

Mobile Phone

Garage Address *

City *

Zip Code *

Mailing Address

State

Zip Code

Driver Information

Driver's Name *

D.O.B. *

Month

Day

Year

Gender *

Male

Female

Marital Status *

Number of Years Driving Experience

Minor Violation in 36 Months

Major Violation in 36 Months

Major Violation in 60 Months

At Fault Accident in 36 Months

At Fault Accident in 60 Months

SR22 / SR1 Filing

Yes

No

License Suspended / Interrupted Within 36 Months

Yes

No

Company Type *

Business Type *

Vehicle Information 1

Model Year *

Make *

Model *

VIN

Vehicle Gross Weight if Commercial

Radius of Operation if *

Body Type

Value of Vehicle *

Trailer

Model Year *

Make *

Type

Value of Vehicle

Limit of Coverage

Bodily Injury / Person :: Injury / Occurence *

Property Damage *

Medical Payment

Uninsured Motorist Liability

Bodily Injury / Person :: Injury / Occurence

Property Damage

Collision Deductible

Other Than Collision Deductible (Comprehensive)

On Hook

Non Owner Auto

Yes

No

Hire Auto

Yes

No

Vehicle Information 2

Model Year

Make

Model

VIN

Vehicle Gross Weight if Commercial

Radius of Operation if

Body Type

Value of Vehicle

Trailer

Model Year

Make

Type

Value of Vehicle

Limit of Coverage

Collision Deductible

Other Than Collision Deductible (Comprehensive)

Vehicle Information 3

Model Year

Make

Model

VIN

Vehicle Gross Weight if Commercial

Radius of Operation if

Body Type

Value of Vehicle

Trailer

Model Year

Make

Type

Value of Vehicle

Limit of Coverage

Collision Deductible

Other Than Collision Deductible (Comprehensive)

Vehicle Information 4

Model Year

Make

Model

VIN

Vehicle Gross Weight if Commercial

Radius of Operation if

Body Type

Value of Vehicle

Trailer

Model Year

Make

Type

Value of Vehicle

Limit of Coverage

Collision Deductible

Other Than Collision Deductible (Comprehensive)

Contact Person *

Phone Number *

Additional Information

Email Address *