STATEMENT: By clicking "submit" I acknowledge I have read the above questions. I declare that the information provided in them is true, compete and correct to the best of my knowledge and belief. This information is being offered to Sixbey Insurance Agency LLC as a request to obtain quotes/proposals for insurance on my behalf.
PLEASE NOTE: This form is provided here for your convenience with the sole purpose of gathering information needed by us to submit applications for insurance to the companies we work with. Completing and submitting this form in no way guarantees an offer for insurance will be made or coverage placed. We may contact you for additional details based on the information provided through this form. Incomplete applications will not be submitted to our carriers. Please contact us by phone or email with any questions. If you would prefer to complete the request for coverage by phone, you may contact us at 716-665-8639. Thank you.
Phone: (716) 665-8639 / Fax: (716) 720-4935 / Email: email@example.com