370 West Park Avenue, P.O. Box 9004, Long Beach, NY 11561-9004
Toll-free: 800-782-8902 Fax: 516-889-5111

Two Minute Drill
-New York-

This survey creates no express or implied obligation on our part to offer a quote or
provide insurance as requested. We may request you to complete a more detailed
application with the assistance of a Lancer authorized insurance producer.

GENERAL INFORMATION
Company Name :
D. B. A. :
Address :
City :   State :   Zip :
Phone # : ( )   Fax # : ( )
Contact Person :   Title :
E-mail Address :
Website:

INFORMATION ABOUT YOUR BUSINESS
# of Years in Business :       Total # of Vehicles :
Type of Operation : Motorcoach # of coaches:
School Bus # of buses:
Transit Bus # of buses:
Limousine # of limos:
Other :
Describe how your vehicles are used:

CURRENT INSURANCE/AGENT INFORMATION
Insurance Company : Expiration Date : mm dd yy
Agency/Brokerage Name :
Address :
City :   State :   Zip :
Phone # : ( )   Fax # : ( )
Contact Person :
E-mail Address :
Would you like a Lancer Agent/Broker to contact you? Yes    No

   


The Survey is copyrighted and material appearing within may not be reproduced in any form without the written permission of Lancer Insurance Company.
All Rights Reserved.

© Lancer Insurance Company, 1997