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Request a Quote

Please complete the following to request a quote from Louis J Brudnick and Sons Insurance. Items that are in RED are required to receive a quote.


Driver Identification:

Name:
Address:
City:
Zip:

Driver Information Section:

State Licensed:
Years of Driving Experience:
If less than 3 years, have you completed a course in Driver Training? YesNo
Drivers Licence Number:
Date of Birth:
Month: Day: Year:

Please check all that apply to the driver:
Over 65:
Purchased a monthly Transit Pass for at least the last 11 months:
Has the driver had any at-fault accidents or moving violations in the past six(6) years?
 Yes:No:
If Yes, please give a brief description:
Vehicle Information:

Make:
Model:
City Primarily Garaged:

Please check all that apply to this vehicle:
Airbags
Automatic Seatbelts
Drive less than 5,000 miles per year
Drive between 5,000 and 7.500 miles per year
Anti-Theft Device Installed
Vehicle Recovery System (e.g.: LoJack/OnStar)

Insurance Coverage:
Mandatory Coverage

1. Bodily Injury to others $20,000 per person / $40,000 per accident
2. Personal Injury Protection $8,000 per person
3. Bodily Injury caused by uninsured:
4. Damage to someone else's property
Optional Coverage:
5. Bodily Injury to Others:
Medical Payments:
7. Collision Coverage Deductible:
8. Limited Collision:
9. Comprehensive Coverage:
10. Substitute Transportation:
11. Towing and Labor:
12. Bodily Injury caused by uninsured:


Contact Information

I would like my quote sent to me via:
Fax Number:
E-Mail Address:
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