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Bouvier Beckwith & Lennox
West Hartford, CT
P 860.232.4491

Root Insurance Agency
East Haddam, CT
P 860.873.8606

E.R. Champion & Son
Old Lyme, CT
P 860.434.1611

Bourgoin Insurance Agency
East Windsor, CT
P 860.623.8207

Clarke Insurance Agency
Manchester, CT 06040
P 860.643.1126

I.F. Mathieu Insurance Agency
Norwich, CT
P 860.887.1617

Automobile Insurance Quote Request

Use this form to request an automobile insurance quote, and we will contact you promptly.

Check here to allow us to run an insurance score.
This allows us to determine the best pricing tier for you.

Your Information

First Name*

Last Name*

Telephone*

Email Address*

Current Address

Mailing Address*

City*

State*

Zip Code*

Own/Rent

Do you rent, own or live with your parents?*
Own Home
Own Condominium
Rent
Live With Parents
Other

Driver Information

Driver One

First Name*

Last Name*

Birth Date*

Marital Status*
Married Single

Gender*
Male Female

Driver License Number

Accidents in the last 5 years?
Yes No

Driver Two

First Name

Last Name

Birth Date

Marital Status
Married Single

Gender
Male Female

Driver License Number

Accidents in the last 5 years?
Yes No

Vehicle Information

Vehicle One

Year

Make

Model

VIN #

Daytime Running Lights
Yes No

Number of Airbags

Anti-lock Brakes
Yes No

Transmission
2-Wheel Drive 4-Wheel Drive

Miles one-way to work or school

Financed
Yes No

Leased
Yes No

Liability Limits

Medical Parts

BRB

Comp Ded/ Full Glass

Collision Deductible

Towing

Rental

Vehicle Two

Year

Make

Model

VIN #

Daytime Running Lights
Yes No

Number of Airbags

Anti-lock Brakes
Yes No

Transmission
2-Wheel Drive 4-Wheel Drive

Miles one-way to work or school

Financed
Yes No

Leased
Yes No

Liability Limits

Medical Payts

BRB

Comp Ded/ Full Glass

Collision Deductible

Towing

Rental

Your Insurance Information

Continuous coverage for the past 6 months?*
Yes No

Current insurance company name?*

BI Limits?

Expiration Date?*

Premium?*

In the last 35 months have you or your spouse experienced any of the following?

revoked or suspended license
bankruptcy
tax lien
sustained any judgements
foreclosure
repossession

Yes No

Are you currently insured with Bouvier Beckwith & Lennox, Inc?
Yes No

Who referred you to us?