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Insurance Quote - Miami's Independent Insurance Agent

Thank you for your interest in B & G Insurance. In order to serve you better and prepare an insurance quote, please take a moment to complete the form below; we will contact you shortly.

Your Personal Information
Your Name *
Street Address
City
State
Zip Code
E-mail Address *
Phone
Alt. Phone
Best method to contact
Best time to contact
Marital Status
Single    Married   
Are you a homeowner?
Yes    No   
Currently Insured?
(If yes, list carrier and the number of years with continuous coverage)
Yes    No   
Type of Insurance coverage needed
Type of vehicle

Commercial Insurance
Type of coverage
Type of business
Year established

Life Insurance
Amount of coverage
Are you a smoker?
Yes    No   
Do you have any life threatening illnesses?
Yes    No   

Driver #1 Information
Name
Birthdate
Sex
Male    Female   
Number of Accidents in the Last 3 Years
Number of Minor Violations in the Last 3 Years
Number of Major Violations in the Last 3 Years
Daily commute one way

Driver #2 Information
Name
Birthdate
Sex
Male    Female   
Number of Accidents in the Last 3 Years
Number of Minor Violations in the Last 3 Years
Number of Major Violations in the Last 3 Years
Daily commute one way

Vehicle #1 Information
Year of Vehicle
Make/Model of Vehicle
Vehicle ID#
Annual Mileage
Is this vehicle used for business?
Yes    No   
If yes, explain briefly

Vehicle #2 Information
Year of Vehicle
Make/Model of Vehicle
Vehicle ID#
Annual Mileage
Is this vehicle used for business?
Yes    No   
If yes, explain briefly

* Required to submit this form




B&G Insurance
5600 SW 135th Ave, Suite 100
Miami, FL 33183
Telephone: 305-386-1006
Fax: 305-386-0840
Email: dottie@bginsuranceteam.com

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