Location: The Motter Agency 262 Allegheny Street Jersey Shore , PA 17740
Email: motteragency@motteragency.com
Go to our Request a Certificate form
Customer Name:
Year / Make / Model of Auto:
VIN:
Address #1:
Address #2:
City
State
Zip Code
Contact Name:
Phone:
Email:
Fax:
Insured Contact For Questions:
Specific Conditions or Limits:
Certificate Holder:
Best Method and Time to Contact:
Name:
Birth Date:
Driver's License#:
Address:
Vehicle: (Year, Make, Model)
Miles drive to work (One Way):
Comprehensive/ Collision Deductibles (if wanted):
Business Name:
Business Type:
Best Method and Time to Contact::
City:
Phone Number:
E-mail:
Year Built:
Sq. Ft:
Acreage:
Age of Roof:
Type of Heat:
Any supplemental heat (wood or pellet stove):
Distance to fire hydrant / fire station:
Other Exposures (Dog, Trampoline, Pool):
Mortgage Holder: