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Welcome to Boardwalk Insurance Group

Auto Insurance Quote

Request an Auto Insurance Quote

General Information

First Name
*
Address 1
City
Zip Code
Night Phone
E-mail Address
*
Last Name
Address 2
State
Country
United States
Day Phone
Best Time to call
(HH:MM)

Please Tell Us About The Vehicle You Drive

Vehicle 1

Year :
Model (Ex: E320 CDI):
VIN # (Optional):
Make (Ex: Mercedes):
Style or Body Type:
Yearly Mileage:

Primary Usage:

Any Custom Equipment On Vehicles? (if YES, give their value & indicate which vehicle):
Where Is The Car Parked Overnight?

Vehicle 2

Year :
Model (Ex: E320 CDI):
VIN # (Optional):
Make (Ex: Mercedes):
Style or Body Type:
Yearly Mileage:

Primary Usage:

Any Custom Equipment On Vehicles? (if YES, give their value & indicate which vehicle):
Where Is The Car Parked Overnight?

Current Insurance Information (if applicable)

Insurance Company Name:
Same Company Policy Since? (YYYY):
Premium Amount Per Month ($):
Policy Expiry Date (MM/DD/YYYY):
Term (Months):

Driver's Information

Driver 1:

Full Name:
DL # (Optional):
Date Of Birth (MM/DD/YYYY):
Occupation:
Sex:
Marital Status:
Education:

Driver 2:

Full Name:
DL # (Optional):
Date Of Birth (MM/DD/YYYY):
Occupation:
Sex:
Marital Status:
Education:

Accidents / Violations In Last 5 Years

Minor Violations - Speeding, Turn, Stop Sign, Red Light, etc.:
(Driver 1)
(Driver 2)
Accidents - Chargeable:
(Driver 1)
(Driver 2)
Major Violations - Drunk driving, Reckless, Hit And Run, etc.:
(Driver 1)
(Driver 2)
Accidents - Non Chargeable:
(Driver 1)
(Driver 2)
Chargeable Accident Cost ($):
(Driver 1)
(Driver 2)
Any additional comments or information that might be helpful in your quote:

Disclaimer

No coverage Of any kind is bound or implied by submitting information via this online form.
  • We will only use information provided to assist in obtaining appropriate insurance quotes and coverage.
  • We will not distribute information to other parties other than for insurance underwriting purposes.
  • By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

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