Auto Quote

Last Name
First Name
M. I.
Physical Address
City
State
Zip
County
Mailing Address (if different)
City
State
Zip
County
Prior Address (if less than 3 years at current location)
City
State
Zip
County
Email
Home Phone
Cell Phone
Work Phone
Present Insurance Company
Renew Date
Car One
Year
Make
Model
Vin #
Usage		Please Select Work/ School Business Pleasure
Miles to Work (One Way)
Annual Mileage
Car Two
Year
Make
Model
Vin #
Usage		Please Select Work/ School Business Pleasure
Miles to Work (One Way)
Annual Mileage
Car Three
Year
Make
Model
Vin #
Usage		Please Select Work/ School Business Pleasure
Miles to Work (One Way)
Annual Mileage
Driver One
Driver Name
Relationship		Please Select Self Spouse Child Other
Date of Birth
Age when US license was first obtained
Driver License Number
State
Driver Improvement Program		Please Select Yes No
If Yes, Date Completed
Gender		Please Select Male Female
Marital Status		Please Select Single Married Divorced
Moving Violations in the last 5 years		Please Select None 1 2 3 4 or More
Please provide date and description of each violation
Accidents in the last 5 years		Please Select 0 1 2 3 4 More
Please provide a date and description of each accident
Have you had insurance canceled, license suspended/ revoked, or been arrested?		Please Select Yes No
Please provide a date and brief description or reason
Driver Two
Driver Name
Relationship		Please Select Self Spouse Child Other
Date of Birth
Age when US license was first obtained
Driver License Number
State
Driver Improvement Program		Please Select Yes No
If Yes, Date Completed
Gender		Please Select Male Female
Marital Status		Please Select Single Married Divorced
Moving Violations in the last 5 years		Please Select None 1 2 3 4 More
Please provide date and description of each violation
Accidents in the last 5 years		Please Select 0 1 2 3 4 or More
Please provide a date and description of each accident
Have you had insurance canceled, license suspended/revoked, or been arrested?		Please Select Yes No
Please provide a date and brief description or reason
Driver Three
Driver Name
Relationship		Please Select Self Spouse Child Other
Date of Birth
Age when US license was first obtained
Driver License Number
State
Driver Improvement Program		Please Select Yes No
If Yes, Date Completed
Gender		Please Select Male Female
Marital Status		Please Select Single Married Divorced
Moving Violations in the last 5 years		Please Select None 1 2 3 4 or More
Please provide date and description of each violation
Accidents in the last 5 years		Please Select 0 1 2 3 4 More
Please provide a date and description of each accident
Have you had insurance canceled, license suspended/revoked, or been arrested?		Please Select Yes No
Please provide a date and brief description or reason
Liability Limit for All Cars
Bodily Injury		Please Select 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,00 300,000/300,000 300,000/500,000 Higher
Property Damage		Please Select 10,000 25,000 50,000 100,000 200,000 500,000 1M
Medical Payments		Please Select 1,000 2,000 3,000 4,000 5,000
Uninsured/Underinsured Motorist Bodily Injury		Please Select 25,000/50,000 50,000/100,000 100,000/300,000 250,000/500,00 300,000/300,000 300,000/500,000 Higher
PIP (Personal Injury Protection)		$50,000 minimum NYS requirement
Additional PIP		Please Select 25,000 50,000 100,000
OBEL (Optional Basic Economical Loss)		Please Select 25,000 Waive
Add Umbrella/Personal Catastrophe Liability Coverage?		Please Select 1M 2M 3M 4M 5M Not at this time
Car One
Deductible Comprehensive		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Deductible Collision		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Towing and Labor		Please Select Yes No
Extended Transportation Comprehensive		Please Select 20 30 40
Extended Transportation Collision		Please Select 20 30 40
Car Two
Deductible Comprehensive		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Deductible Collision		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Towing and Labor		Please Select Yes No
Extended Transportation Comprehensive		Please Select 20 30 40
Extended Transportation Collision		Please Select 20 30 40
Car Three
Deductible Comprehensive		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Deductible Collision		Please Select 100 100 with Glass 250 250 with Glass 500 500 with Glass 1,000 1,000 with Glass Higher
Towing and Labor		Please Select Yes No
Extended Transportation Comprehensive		Please Select 20 30 40
Extended Transportation Collision		Please Select 20 30 40

Bradley Agency Disclaimer for On-Line Quote By choosing to use this web site (bradleyagency.com) to request an insurance quote, you agree to the following terms and conditions. The materials and information contained in this web site are provided “as is” and without warranty of any kind, either expressed or implied.  The Bradley Agency assumes no liability whatsoever for damages of any kind incurred as a result of your request for a quote or use of this website. Your request for an insurance quote will not bring into effect any insurance coverage.  Insurance coverage may only be effected when your application for insurance is accepted by the Bradley Agency and approved by the carrier as evidenced by the inception date as indicated on a policy. Your entire quote, including the estimated premium and the prospective terms of coverage are tentative and are subject to change without notice based on any and all underwriting criteria, rating dates, manuals, plans and classifications used by Bradley Agency. In the event that there is a difference in the information, rates, premiums or terms contained in a quote and any insurance policy issued to you by the Bradley Agency, the policy governs.