About Clifford M. Golub
Associates, Inc.

Foremost Group
Interborough Mutual
Statewide
Travelers
Aetna US Healthcare
MDNY · GHI · HIP ·
Oxford ·
United Healthcare·
Vytra Health Plans· 

Insurance quotes can always be obtained by calling us at (516) 935-7230 or (718) 287-6875. Or, for your convenience you can simply complete and submit this form and we will get back to you. Please understand that submission of this form does NOT constitute insurance coverage.

Your Name: E-mail Address Your Telephone Number: Your Street Address: Your City, State, and Zip: Current Insurance Company:		Current Premium: Expiration Date: Liability Limit $: Bodily Injury Liability $: No Fault (PIP) $:
Information About Your Car(s):
Year of Car#1: Make: Model: Annual Mileage: Liability Limit $: Bodily Injury Liability $: No Fault (PIP) $: Air bags? Yes No Anti Theft Device? Yes No Anti Lock Brakes? Yes No Daytime running lights? Yes No Passive Restraints? Yes No	Year of Car#2: Make: Model: Annual Mileage: Liability Limit $: Bodily Injury Liability $: No Fault (PIP) $: Air bags? Yes No Anti Theft Device? Yes No Anti Lock Brakes? Yes No Daytime running lights? Yes No Passive Restraints? Yes No	Year of Car#3: Make: Model: Annual Mileage: Liability Limit $: Bodily Injury Liability $: No Fault (PIP) $: Air bags? Yes No Anti Theft Device? Yes No Anti Lock Brakes? Yes No Daytime running lights? Yes No Passive Restraints? Yes No	Year of Car#4: Make: Model: Annual Mileage: Liability Limit $: Bodily Injury Liability $: No Fault (PIP) $: Air bags? Yes No Anti Theft Device? Yes No Anti Lock Brakes? Yes No Daytime running lights? Yes No Passive Restraints? Yes No
Comments?
Information About The Driver (s):
Driver #1	Driver #2	Driver #3	Driver #4
Sex: Male Female Marital Status: Married Single Date of Birth: Dates/descriptions of accidents, violations or claims: Dates/descriptions of any defensive driving classes:	Sex: Male Female Marital Status: Married Single Date of Birth: Dates/descriptions of accidents, violations or claims: Dates/descriptions of any defensive driving classes:	Sex: Male Female Marital Status: Married Single Date of Birth: Dates/descriptions of accidents, violations or claims: Dates/descriptions of any defensive driving classes:	Sex: Male Female Marital Status: Married Single Date of Birth: Dates/descriptions of accidents, violations or claims: Dates/descriptions of any defensive driving classes: