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BGES Group
216 A Larchmont Acres W
Larchmont, NY 10538

"All Our Policies Come With
an Agent!"

On-Line Automobile Insurance Quote Form One Simple Form - takes only 2-3 Minutes! Your Personal Data
Your Name:
Street Address:
City:
State: (Must be New York)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):

Marital Status: Single Married	Homeowner? Yes No

Currently Insured? (If yes, list carrier, and # of years continuous. If none, type N/C)

DRIVER INFORMATION #1

Name: Birthdate:

Sex (M/F): # Years U.S.
Licensing:

Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations, and approximate DATES of each in the fields below:

Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:

Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:

Does Driver need
an SR22 FILING? Yes No If YES to SR22 filing, why needed?
(list accident/cite)

DRIVER INFORMATION #2 (if none, leave blank)

Name: Birthdate:

Sex: # Years U.S.
Licensing:

Be specific to tell if accidents are "at-fault" or "NOT-at-fault" - (carriers require proof on NOT-at-fault accidents); Also, be specific as to TYPE of violations in fields below:

Number & Type of Accidents last 3 years: Number & Type of MINOR Cites last 3 years:

Number & Type of MAJOR Cites last 3 years: Daily commute
in ONE WAY miles:

Does Driver need
an SR22 FILING? Yes No Comments or
Remarks?

If More than 2 Drivers, list Additional Driver's Names, Birthdates, and driving record history here:

VEHICLE #1 INFORMATION
(if "Non-Owners", type "NON-OWNER" in "YEAR" Field)

Year of vehicle: Make & Model:

Annual Mileage: Used in business?
(Explain, if yes):

VEHICLE #1 COVERAGES:

Limits of
Liability: $100/300 BI / 100 PD $250/500 BI / 100 PD $300,000 CSL $500,000 CSL
$1 Million + (Quote Umbrella)

Comprehensive
Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Collision
Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Rental Car &
Towing Coverage? YES NO

VEHICLE #2 INFORMATION (if none, leave blank)

Year of vehicle: Make & Model:

Annual Mileage: Used in business?
(Explain, if yes):

VEHICLE #2 COVERAGES:

Limits of
Liability: $100/300 BI / 100 PD $250/500 BI / 100 PD $300,000 CSL $500,000 CSL
$1 Million + (Quote Umbrella)

Comprehensive Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Collision
Coverage: NO Coverage $250 Deductible
$500 Deductible $1000 Deductible

Rental Car &
Towing Coverage? YES NO

Comments or Remarks:
(List additional drivers, autos, etc. here)

If More than 2 Vehicles, list Additional Vehicles Year, Makes, and Models here:

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Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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