16-00 Pollitt Dr (map/directions)
Fair Lawn, New Jersey 07410
Call: (201) 254-1888
Fax: (201) 797-4455
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Print, complete, and fax this form to (201) 471-3634, Attn: Mike Best.
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Please call us directly at (201) 254-1888 for the fastest response.
Company Name:____________________________________________________
Contact Person:____________________________________________________
Contact E-mail:_____________________________________________________
Contact Phone: ____________________________________________________
Circle all the types of insurance you would like help with:
Business, Personal, Life, Health, Surety Bonds, and/or Other.
Comments_________________________________________________________
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The insurance companies our agency represents use information from you and other sources,
such as your driving record and claim history, to calculate accurate prices for your insurance.
These insurance companies may also request your credit report and use insurance scoring to
determine the insurance premium you will be charged. New or updated information may be used
to calculate your renewal premium. The insurance companies privacy policy explains how they
disclose and protect your personal information and how you may access and correct it. Our
agency can provide a copy at your request.
Please note: Policy coverages or limits of insurance are not bound or amended without written
confirmation from our office.
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