New York auto, homeowners and business insurance from My CNY Agent.com
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Account Request Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name
Street Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
Phone (REQUIRED):
Fax: (Optional)
 
Policy & Service Details
 
Your Policy Number:
 
 
What do You Need? Policy change
Insurance Certificate
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Other
 
 
Describe Your Service Need in DETAIL:

(If you need a certificate of insurance, list name and complete address of certificateholder here.)

 
Please contact me for service via: Fax E-Mail
Regular Mail
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Thank you for filling out this form COMPLETELY!

We deem your data submitted as PRIVATE information. Every step has been taken to insure your privacy, security, and to release this information only to you. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Also, the insurance carriers reserve the right to issue coverage or not, and we cannot guarantee acceptance of a risk until approved by the company.

Yes, Please Service My Account. I Understand that NO COVERAGE IS BOUND on insurance changes until confirmed IN WRITING BY OUR AGENCY.

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My CNY Agent, Inc.
MAIN OFFICE: 2273 Downer Street Road . Baldwinsville, NY 13027
Local Phone: 315-635-0050 . Fax: 888-859-3459
MANLIUS, NY OFFICE: 314 East Seneca St. . Manlius, NY 13104 . Phone: 315-682-1001
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