DG&M Agency Inc.

General Information

First Name:
Middle Initial:
Last Name:
Address:
Address:
City:
State:	Zip:
Phone:	Fax:
E-mail

Driver Information:

	Driver 1	Driver 2	Driver 3
First Name:
Middle Name:
Last Name:
NY Drivers License #:
Date of Birth: (00/00/00)
Gender:
Marital Status:
Type:
Year:
Make:
Model:
VIN or Serial #:
Please check any Violations for each driver in the last three years:	None Speeding(less than 15 mph over limit) Speeding(more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other	None Speeding (less than 15 mph over limit) Speeding (more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other	None Speeding (less than 15 mph over limit) Speeding (more than 15 mph over limit) Stop sign Traffic Light DUI/DWI Reckless Driving Eluding Police Homicide with vehicle Drag Racing Suspension Other
Please check any Accidents for each driver in the last three years:	None At fault accident Not at fault accident Hit and Run Other	None At fault accident Not at fault accident Hit and Run Other	None At fault accident Not at fault accident Hit and Run Other
Boat: Value of Hull
Boat: Value of Contents
Boat: Value of Fishing Equipment
Please check all that apply:	None Loran Radio Need Info Other	None Loran Radio Need Info Other	None Loran Radio Need Info Other
Please check all that apply:	None Completed approved Boater Safety Course Completed approved Motorcycle Safety Course Member of approved Motorcycle Association Other	None Completed approved Boater Safety Course Completed approved Motorcycle Safety Course Member of approved Motorcycle Association Other	None Completed approved Boater Safety Course Completed approved Motorcycle Safety Course Member of approved Motorcycle Association Other

For more information on our recreational vehicle products and companies, please contact: Karen Annechino -

E-mail: kannechino@dgmagency.com