Request for Insurance Quote For Commercial Vehicles

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Welcome to the Bennett Brokerage Virtual Insurance Office. Please fill out the following request and submit it to us and one of our representatives will contact you within 24 hours with a quote. Upon your acceptance of our quote, we have included on our site our complete application form.

Name:

Garage Address:

Phone Number:

Zip Code:

Are you a Homeowner? Yes No

Do you lease or have purchased your vehicle? Lease Purchased

Use of Vehicle:

Year of Vehicle:

Make of Vehicle:

Model of Vehicle:

Doors: 2 Door 4 Door Wagon

Do you currently have auto insurance for the past 6 continuous months? Yes No

Driver Information:

Sex: Female Male

Marital Status: Single Married

Number of years Licensed: Over 3 years Under 3 years

Date of Birth:

Do you have moving violations within the last 5 years? Please list.

Did you have accidents within the last 5 years? Please list.

ALL FORMS OF INSURANCE

The Bennett Brokerage Inc.

2290 Babylon Turnpike, Suite A

Merrick, NY 11566

PHONE: 516-223-4902

FAX: 516-223-5359

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