Bleiler Insurance

Best Insurance Coverage | Allentown, PA

Bleiler Insurance

615 N. 20th Street,
Allentown, PA 18104

610-435-3802

info@bleilerinsurance.com

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Auto Quote

This form is used for both personal auto and Auto Insurance Lehigh Valley – Auto Quote. Kindly complete this form and submit so we can prepare your business auto insurance quote.

    General Information

    Name: *

    Business Name:

    Address:

    City: State: Zip:

    Day Phone:

    Evening Phone:

    Best time to contact: AMPM

    E-mail address: *

    Occupation:

    Current Insurance Section

    Company: (Not Agency, If no current insurance mark "none")

    Policy Expiration Date: (xx/xx/xxxx)

    Annual Premium:

    Term:
    6 months1 year

    Driver Section

    Driver 1

    Driver's Name:

    Date of Birth:

    License Number:

    State: Years Licensed:

    Relation:

    Gender: MaleFemale

    Marital Status: SingleMarried

    Driver 2

    Driver's Name:

    Date of Birth:

    License Number:

    State: Years Licensed:

    Relation:

    Gender: MaleFemale

    Marital Status: SingleMarried

    Driver 3

    Driver's Name:

    Date of Birth:

    License Number:

    State: Years Licensed:

    Relation:

    Gender: MaleFemale

    Marital Status: SingleMarried

    Driver 4

    Driver's Name:

    Date of Birth:

    License Number:

    State: Years Licensed:

    Relation:

    Gender: MaleFemale

    Marital Status: SingleMarried

    Vehicle Section

    Vehicle 1

    Make:

    Model: Year:

    GVW: (for business auto only)

    Vehicle Value: (for business auto only)

    VIN #:

    Primary Driver:

    Annual Mileage:

    Is this vehicle used to commute to work or school?
    YesNo

    If yes, what is the number of miles one way?
    miles.

    Is this vehicle used for business use?
    YesNo

    Vehicle 2

    Make:

    Model: Year:

    GVW: (for business auto only)

    Vehicle Value: (for business auto only)

    VIN #:

    Primary Driver:

    Annual Mileage:

    Is this vehicle used to commute to work or school?
    YesNo

    If yes, what is the number of miles one way?
    miles.

    Is this vehicle used for business use?
    YesNo

    Vehicle 3

    Make:

    Model: Year:

    GVW: (for business auto only)

    Vehicle Value: (for business auto only)

    VIN #:

    Primary Driver:

    Annual Mileage:

    Is this vehicle used to commute to work or school?
    YesNo

    If yes, what is the number of miles one way?
    miles.

    Is this vehicle used for business use?
    YesNo

    Vehicle 4

    Make:

    Model: Year:

    GVW: (for business auto only)

    Vehicle Value: (for business auto only)

    VIN #:

    Primary Driver:

    Annual Mileage:

    Is this vehicle used to commute to work or school?
    YesNo

    If yes, what is the number of miles one way?
    miles.

    Is this vehicle used for business use?
    YesNo

    Coverage Section

    Liability and First Party Benefits

    Bodily Injury:

    Property Damage:

    Single Limit:

    Uninsured & Underinsured Motorist Split Limits Coverage:

    Uninsured & Underinsured Motorist Single Limit Coverage:

    Uninsured & Underinsured Motorist: StackedUnstacked

    Extraordinary Medical Benefits:

    First Party Medical Benefits:

    Accidental Death Benefits:

    Income loss:

    Funeral Benefits:

    Towing Coverage:

    Rental Reimbursement / Loss of Use:

    Tort Option:

    Deductibles and Miscellaneous

    Vehicle 1

    Deductibles

    Comprehensive:

    Collision:

    Vehicle 2

    Deductibles

    Comprehensive:

    Collision:

    Vehicle 3

    Deductibles

    Comprehensive:

    Collision:

    Vehicle 4

    Deductibles

    Comprehensive:

    Collision:

    Additional Questions and Comments

    In order to provide you with an accurate quote the company will obtain your credit insurance score and additional reports to verify the driving records and claims history for the person / persons applying for the insurance. This will not have an effect on your credit history.

    *   I have read the Information Disclosure and accept the above terms and conditions

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    A Little About Us

    The Bleiler Insurance Agency is an independent insurance agency providing business owners and families throughout the Lehigh Valley located in Allentown, PA with the best coverage at competitive prices. We’re a family owned and operated agency in Lehigh Valley, PA with a well trained and experienced staff.

    Bleiler Insurance

    615 N. 20th Street
    Allentown, PA 18104

    Phone: 610-435-3802

    Email: info@bleilerinsurance.com

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    We serve the entire Lehigh Valley and surrounding areas including Allentown, Easton, Bethlehem, Whitehall, Northampton, Schnecksville, Macungie, Fogelsville.

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