Britton-Selg-Stanford Agency Automobile Insurance Quote
For a quick and accurate automobile insurance quote, please fill in as much information possible. The more information submitted the more accurate your quotation can be.
Please fill out the feed back form below, after you are finished just click on the submit button and an agency representative will get back to you as soon as possible
Name:
Address:
City:
State:
Zip:
Email Address:
Daytime Phone:
Evening Phone:
Policy Information
Present Insurance Company:
Policy #:
Policy Dates: To
Liability
Number Of Autos:
Married or Single
Any other drivers in the household? If Yes, please list in the "Additional Information" box below.
Any losses or violations in the last three years? If Yes, please list in the "Additional Information" box below.

Auto1: Yr Make Model Vin #
ABS Brakes / Driver side Airbags / Dual Airbags / Passive Alarm System / LoJack
Comprehensive Deductible: Collision Deductible:
Leased: Financed:
Auto2: Yr Make Model Vin #
ABS Brakes / Driver side Airbags / Dual Airbags / Passive Alarm System / LoJack
Comprehensive Deductible: Collision Deductible:
Leased: Financed:
Auto3: Yr Make Model Vin #
ABS Brakes / Driver side Airbags / Dual Airbags / Passive Alarm System / LoJack
Comprehensive Deductible: Collision Deductible:
Leased: Financed:
Registered Owner on each Auto
1:
2:
3:
4:
5:
Drivers Licence #:
1: Name Date of Birth Licence # State
2: Name Date of Birth Licence # State
3: Name Date of Birth Licence # State
4: Name Date of Birth Licence # State
5: Name Date of Birth Licence # State
Additional Information

Britton-Selg-Stanford Agency
327 Chestnut Street
Roselle Park, NJ 07204

Tel. (908) 241-1180
Toll Free 800-352-1018
Fax (908) 241-0808


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