TLC Insurance

All Inclusive programs provide the student with 30 hours of class, and all class materials. We offer weekday classes, Saturday/Sunday classes, Saturday only, and Sunday only classes

Program Overview

Please fill up and submit the following form, and we’ll give you a call back as soon as possible. Or contact us through phone or email to provide necessary details to get started with the quote.

Basic Information Other Information

Date

Risk Type

Effective Date

Expiration Date

Note

APPLICATION INFORMATION

Mobile Number

Email Address

SSN/FED TAX ID

Driver License #

HACK License #

PRODUCERS INFORMATION

Phone Number

Year

0 / 4

Make

VIN Number

Plate Number

IS THE FOLLOWING DESCRIBED VEHICLE RATED BY THE TLC TO BE "WHEEL CHAIR ACCESSIBLE"?

IS THE VEHICLE LISTED BELOW A "HYBRID VEHICLE"?

IF MARRIED PLEASE ENTER THE SPOUCE'S NYC LICENSE Number

TLC Approved Radio Base

TLC Radio Base License#

TLC Phone Number

Vehicle Base Number

LC MANDATED LIMITS OF LIABILITY

BI $100,000 / $300.000 PD $10,000 BPIP $50,000 APIP $150,000 UM $25,000 / $50,000 SUM $25,000 / $50,000

DRIVERS INFORMATION

Driver 1

Driver Name

Address

State

Phone

Relationship

FOR THE APPLICANT, LIST THE NAME OF THE PREVIOUS CARRIER AND LOSS EXPERIENCE FOR THE PAST 36 MONTHS

Insurance Company

Policy Number

Period Covered

# of Claims Rep.

# of Violations

Applicant's Signature

Drag and Drop (or) Choose Files

Drivers's Signature

Drag and Drop (or) Choose Files

Producer's Signature

Drag and Drop (or) Choose Files

AN ANNUAL SERVICE FEE OF $20.00 WILL BE CHARGED PER INSTALLMENT

Aproved

Class Assigned

Date

Declined

Application declined for the following reason

Date

Phone

Tell: (646)-496-3480
Cell: (646)-496-3480
Fax:

Operating Hours

Open: 7 Days

Office Hours : 10:00 AM - 8:00 PM

TLC Insurance

Program Overview

APPLICATION INFORMATION

PRODUCERS INFORMATION

LC MANDATED LIMITS OF LIABILITY

DRIVERS INFORMATION

FOR THE APPLICANT, LIST THE NAME OF THE PREVIOUS CARRIER AND LOSS EXPERIENCE FOR THE PAST 36 MONTHS

AN ANNUAL SERVICE FEE OF $20.00 WILL BE CHARGED PER INSTALLMENT

Phone

Operating Hours

Insurance Service Registration Form

CLIENT INFORMATION