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:

Social Security Number:

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:

TowingRental Reimbursement / Loss of Use

Vehicle 2

Deductibles

Comprehensive:

Collision:

TowingRental Reimbursement / Loss of Use

Vehicle 3

Deductibles

Comprehensive:

Collision:

TowingRental Reimbursement / Loss of Use

Vehicle 4

Deductibles

Comprehensive:

Collision:

TowingRental Reimbursement / Loss of Use

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

Please enter this code in the box below:

General Information

Current Insurance Section

Driver Section

Vehicle Section

Coverage Section

Additional Questions and Comments

A Little About Us

Bleiler Insurance

Connect With Us