Name: The Excelsior Group
Address: 71 South Central Ave., Valley Stream, NY, 11580, US
Telephone: (516) 568-0800

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Personal Information
Name:*
Address:
Street Address City State ZIP Code
Phone:*
Email:*
Are You Currently Insured?:*
- Yes
- No
Current Insurance Information
Insurance Company Name (not agency):
Policy Expiration Date:
Month
Day
Year
Years Insured:
Premium Amount:
Term
- 6 Months
- 1 Year
ATV Information
How many ATV's do you own?
- One
- Two
- Three
ATV #1 Information
Year:
Make:
Model:
Engine Size:
Cost New:
Comprehensive Deductible:
Collision Deductible:
If ATVs are kept at an address other than that listed above, please indicate below:
Street Address Address Line 2 City State ZIP Code
ATV #2 Information
Year:
Make:
Model:
Engine Size:
Cost New:
Comprehensive Deductible:
Collision Deductible:
ATV #3 Information
Year:
Make:
Model:
Engine Size:
Cost New:
Comprehensive Deductible:
Collision Deductible:
Liability Limits For All ATV's
Choose Either:
- Bodily Injury & Property Damage
- Single Limit
Bodily Injury:
Property Damage:
Single Limit:
Driver Information
How many licensed drivers in your household?
- One
- Two
- Three
- Four
Driver #1 Information
Name
First Last
Relation:
Number of Years Licensed:
Date of Birth:
Gender:
- Male
- Female
Marital Status:
- Married
- Single
ATV Safety Class:
- Yes
- No
License Suspended or Revoked?
- No
- Yes, Suspended
- Yes, Revoked
- Yes, Both
DUI Conviction?
- No
- Yes, For Alcohol
- Yes, For Drugs
- Yes, Drugs & Alcohol
Driver #2 Information
Name
First Last
Relation:
Number of Years Licensed:
Date of Birth:
Gender:
- Male
- Female
Marital Status:
- Married
- Single
ATV Safety Class:
- Yes
- No
License Suspended or Revoked?
- No
- Yes, Suspended
- Yes, Revoked
- Yes, Both
DUI Conviction?
- No
- Yes, For Alcohol
- Yes, For Drugs
- Yes, Drugs & Alcohol
Driver #3 Information
Name
First Last
Relation:
Number of Years Licensed:
Date of Birth:
Gender:
- Male
- Female
Marital Status:
- Married
- Single
ATV Safety Class:
- Yes
- No
License Suspended or Revoked?
- No
- Yes, Suspended
- Yes, Revoked
- Yes, Both
DUI Conviction?
- No
- Yes, For Alcohol
- Yes, For Drugs
- Yes, Drugs & Alcohol
Driver #4 Information
Name
First Last
Relation:
Number of Years Licensed:
Date of Birth:
Gender:
- Male
- Female
Marital Status:
- Married
- Single
ATV Safety Class:
- Yes
- No
License Suspended or Revoked?
- No
- Yes, Suspended
- Yes, Revoked
- Yes, Both
DUI Conviction?
- No
- Yes, For Alcohol
- Yes, For Drugs
- Yes, Drugs & Alcohol
Driving History
Please list any convictions for any driver convicted of moving traffic violations in the past 5 years:
Driver: Date: Type of Conviction: Fines ($): Speed over limit (mph):
Please list any driver involved in accidents, regardless of fault, in the past 5 years
Driver: Date: Description: Cost($): Fines($): At Fault (Yes or No):
Excess Liability
Personal Umbrella Coverage:
- Yes
- No
Amount:
Additional Comments or Questions
Email
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The Excelsior Group

71 South Central Ave.
Valley Stream, New York 11580

Phone: (516) 568-0800

Fax: (516) 568-0809

Toll Free: (800) 566-0801

Office Hours
Mon-Fri: 9:00am-5:00pm
Sat-Sun: Closed

The Excelsior Group Provides auto insurance, home insurance, life insurance, health insurance, business insurance, and employee benefits to all of New York, including Valley Stream, and New York City.

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Driver:	Date:	Type of Conviction:	Fines ($):	Speed over limit (mph):

Driver:	Date:	Description:	Cost($):	Fines($):	At Fault (Yes or No):

We Want Your Opinion!

Personal Information

Current Insurance Information

ATV Information

ATV #1 Information

ATV #2 Information

ATV #3 Information

Liability Limits For All ATV's

Driver Information

Driver #1 Information

Driver #2 Information

Driver #3 Information

Driver #4 Information

Driving History

Excess Liability

Additional Comments or Questions