The Burtnett Agency LLC
600 East Penn Street Bedford, PA 15522
(814) 623-8419
Whatever your insurance needs may be,
call The Burtnett Agency.
Personal Information
Your name:
Your email address:
Your phone number:
Street:
City:
State:
Current Insurance Company:
Zip:
Driver Information
Driver #1
Driver #2
First Name:
First Name:
Middle:
Middle:
Last Name:
Last Name:
Suffix:
Suffix:
Birth Date:
Birth Date:
Drivers License #:
Drivers License #:
Driver #3
Driver #4
First Name:
First Name:
Middle:
Middle:
Last Name:
Last Name:
Suffix:
Suffix:
Birth Date:
Birth Date:
Drivers License #:
Drivers License #:
Vehicle Information
VEH # 2
VEH # 1
VIN #:
VIN #:
YEAR:
YEAR:
MAKE:
MAKE:
MODEL:
Model:
Work or Pleasure?:
Work or Pleasure?:
Comp Deductible:
Comp Deductible:
Collision Deductible:
Collision Deductible:
Towing?:
Towing?:
Ext. Transportation?:
Ext. Transportation:
Driver Name:
Driver Name:
VEH # 4
VEH # 3
VIN #:
VIN #:
YEAR:
YEAR:
MAKE:
MAKE:
MODEL:
MODEL:
Work or Pleasure?:
Work or Pleasure?:
Comp Deductible:
Comp Deductible:
Collision Deductible:
Collision Deductible:
Towing:
Towing?:
Ext. Transportation:
Ext. Transportation:
Driver Name:
Driver Name:
Coverage Information
Coverages
Bodily Injury Liability:
Property Damage:
Underinsured Motorist:
Uninsured Motorist:
Stacked?:
Medical:
Income Loss:
Funeral:
AD&D:
Tort - Full or Limited:
For an auto insurance quote please fill
in the form and submit. We will be in
contact with you as soon as possible.