Commercial Vehicle Quote Request from NY Contractor's Insurance.com

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BGES Group
216 A Larchmont Acres W
Larchmont, NY 10538

"All Our Policies Come With
an Agent!"

On-Line Commercial Vehicle Quote Form One Simple Form - takes only 2-3 Minutes! YOUR PERSONAL DATA:
Your Name:
Business Name:
Street Address:
City:
State:	MUST be New York!
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):

Currently Insured? (If yes, list carrier, and # of years continuous. If no, type NONE)

Type of Business: (Please be specific, and tell how vehicles are used.)

DRIVER INFORMATION #1
(if more than two drivers,
list in remarks)

Name: Birthdate:

Sex: # Years U.S.
Auto License:

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

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

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

DRIVER INFORMATION #2 (if none, leave blank)

Name: Birthdate:

Sex: # Years U.S.
Auto License:

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

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

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

COMMERCIAL VEHICLE #1:
If more than 2 vehicles, list in remarks
or CALL US at: 914-806-5853

Year of vehicle: Make & Model:

Type (truck, tow-truck, bobtail, etc.): Length in Feet:

Radius of operation: Value $:

List Special Equipment & Values
(i.e., rack, tool box, etc.)

VEHICLE #1 COVERAGES:

Limits of
Liability: $15/30 BI / 10 PD $25/50 BI / 15 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD
$250/500 BI / 100 PD $1 Million

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

Do you want
Medical Coverage? Yes No   Uninsured
  Motorists? Yes No

COMMERCIAL VEHICLE #2:

Year of vehicle: Make & Model:

Type (truck, tow-truck, bobtail, etc.): Length in Feet:

Radius of operation: Value $:

List Special Equipment & Values
(i.e., rack, tool box, etc.)

VEHICLE #2 COVERAGES:

Limits of
Liability: $15/30 BI / 10 PD $25/50 BI / 15 PD
$50/100 BI / 25 PD $100/300 BI / 50 PD
$250/500 BI / 100 PD $1 Million

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

Do you want
Medical Coverage? Yes No   Uninsured
  Motorists? Yes No

Send my quotation via: E-Mail Fax
Regular Mail
Call Me by Phone

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.

Yes, I Agree. Please Send Me a
Commercial Vehicle Quote NOW!

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