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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: Address:

Garage Zip Code:

Phone Number:Email Address:

In order to receive an accurate quote your license number and social security number would be requested:

License Number:

Social Security Number:

Are you a Homeowner? Yes No

Do you lease or have purchased your vehicle? Lease Purchased

Vehicle 1:

Year of Vehicle 1:Make of Vehicle 1:

Model of Vehicle 1:Doors of Vehicle 1: 2 Door 4 Door Wagon

Vehicle 2:

Year of Vehicle 2:Make of Vehicle 2:

Model of Vehicle 2:Doors of Vehicle 2: 2 Door 4 Door Wagon

Vehicle 3:

Year of Vehicle 3:Make of Vehicle 3:

Model of Vehicle 3:Doors of Vehicle 3: 2 Door 4 Door Wagon

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

Number of licensed drivers in household:

Driver Information:

Driver 1

Sex of Driver 1 : Female Male Marital Status of Driver 1: Single Married

Number of years Licensed for Driver 1: Over 3 years Under 3 years

Date of Birth of Driver 1:

Driver 2

Sex of Driver 2 : Female Male Marital Status of Driver 2: Single Married

Number of years Licensed for Driver 2: Over 3 years Under 3 years

Date of Birth of Driver 2:

Relationship of Driver 2 to Principal Driver:

Driver 3

Sex of Driver 3 : Female Male Marital Status of Driver 3: Single Married

Number of years Licensed for Driver 3: Over 3 years Under 3 years

Date of Birth of Driver 3:

Relationship of Driver 3 to Principal Driver:

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

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

Please submit any additional information that will insure the accuracy of your quote.

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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