Biondi Franklin Insurance Agency - your full service insurance agency in Northeastern Pennsylvania since 1979
Independent Agents proudly representing the Erie Insurance Group
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Biondi Franklin Insurance
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Auto Insurance Quote
Northeastern Pennsylvania Only

     
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Name*
Address*
City* State* Zip:*
Please supply either a Daytime or Evening Phone Number
and the best time to call.
Day Time Number:
Evening Number: (570)
Best Time To Call*
E-mail:*

Request Auto Insurance

Do you currently own your own home*
Current insurance carrier*
(If you do not have a current insurance carrier type in NONE)
How Long*   years
Policy Expiration Date
Driver Information
Driver1* Driver2 Driver3
Name*
License #*
Soc. Sec #*
Sex*
Date
of Birth*
Tickets
in last
3 years*
Accidents
in last
3 years*
Years
Licensed*
Daily
Commute
 miles  miles  miles
Vehicle Information
Vehicle1* Vehicle2 Vehicle3
Year*
Make*
(i.e. Pontiac)
Model/Trim
(i.e. Bonneville)
Body Style
(i.e. 2-door)
Cylinders
Passive Restraints*
Anti-Theft Device*
Used
for
Business
Total
Annual
Miles
VIN#
Limit
of
Liability
$ $ $
Limit of
Property
Damage
$ $ $
Comprehensive
Deductible
$ $ $
Collision
Deductible
$ $ $
1st Party
Medical Expenses

(If other,
please specify
$
$
$
1st Party
Income Loss

(If other,
please specify
$
$
$
Accidental
Death

(If other,
please specify
$
$
$
Funeral
Expenses

(If other,
please specify
$
$
$
Transportation
Expenses

(If other,
please specify
$
$
$
Uninsured
Motorist
$ $ $
Underinsured
Motorist
$ $ $
Underinsured/Uninsured
Stacking Applies
$ $ $
Tort Option $ $ $
Road Service $ $ $

Additional Information:

(If you have any ticket or accidents please explain here
Also provide information about fourth driver and/or vehicle here)


NOTE: All asterisked* fields must be completed for a successful submission. Thanks!


One of our agents will contact you shortly with your proposed coverage


 
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Biondi-Franklin Insurance Agency
790 Northern Boulevard
Clarks Summit, PA 18411
570-587-2840
info@qualityinsurance.com

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