New York Insurance by Bermack, Champion & Lewine for Auto, Homeowners, Business and Personal Insurance
This website offers services primarily to current and future residents of NY, CT and NJ.
14 Penn Plaza, Suite 1611, New York NY 10122, Tel. (212) 239-1140  
 
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Automobile Quote - 1 Driver, 1 Vehicle
The quotes provided here are for NY, NJ and CT only.
Fill out the form below to obtain an auto quote. To obtain an accurate quote, please be as complete as possible. This form is designed for quoting on one vehicle and one driver. For additional vehicles or drivers, see our Family Quote or feel free to call us.
The quotes provided here are for NY, NJ and CT only.
Vehicle(s) Registration Information Section
The name and address to which the vehicle(s) is or will be registered:
Name:
Street:
City/State/Zip: / /
Home Phone: Work Phone:
Email Address:
Driver Information Section          Review Sections:
Driver Name : Driver 1
As it appears on license
State Licensed: Driver 1
Years of Driving Experience: Driver 1
Drivers License Number: Driver 1 
Date of Birth Driver 1
Social Security Number: Driver 1
Please check what applies to the driver: Driver 1 Defensive Driving Course Completed
Drivers Ed (males <21 years old only)
Claims, tickets, accidents (regardless of fault), suspensions or revocations in last 5 years: Driver 1
Vehicle Information Section          Review Sections:
Year Vehicle 1
Make Vehicle 1
Model
(Please be as specific as possible. ie. Honda Accord LX, 4 door)
Vehicle 1
City Primarily Garaged: Vehicle 1
Please check all that apply to this vehicle.    
Airbags Vehicle 1
Automatic Seatbelts Vehicle 1
Daytime Running Lights Vehicle 1
Antilock Braking System (ABS) Vehicle 1
Antitheft device (Alarm) Vehicle 1
Vehicle Recovery System (LoJack) Vehicle 1
Insurance Coverages Section          Review Sections:
Bodily Injury to Others: Vehicle 1
Damage to someone else's property: Vehicle 1
Liability CSL : Vehicle 1
Bodily Injury caused by Uninsured Motorist: Vehicle 1
Personal Injury Protection Deductible: Vehicle 1
Personal Injury Basic: Vehicle 1 $50,000
Additional Personal Injury: Vehicle 1
Optional Basic Economic Loss: Vehicle 1 $25,000
Comprehensive Collision/Deductible: Vehicle 1
Medical Payments: Vehicle 1
Full Glass Coverage: Vehicle 1
Towing and Labor: Vehicle 1 $50 per incident
Substitute Transportation: Vehicle 1
    End of Form                          Review Sections:
Select Response Method, then
click the Submit button below
Response Method
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          Fax Number:
          Mailing Address: Street:
  City/State/Zip: / /


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Comments:



          

We will send your quote promptly.
Thank you for considering Bermack, Champion & Lewine!




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