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3201 N. Atlantic Ave.Cocoa Beach , FL
storefront motorcycle car group of happy employees nice neighborhood yacht
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Get a Quote

At Brevard Insurance & Marketing, we leave the cute commercials and promises of outrageous discounts for car insurance to the big guys. Instead, we focus on creating quality, comprehensive auto policies at affordable prices delivered by an experienced, knowledgeable staff.

Whether you need to coverage for your standard automobiles, classic cars, motorcycles, recreational vehicles or watercraft, let us review your insurance needs and tailor a program specifically for you.

Start a Free Rate Quote or call us at (321) 783-2404 and let the agents at Brevard Insurance & Marketing demonstrate why we are one of the leading independent insurance agencies in Cocoa Beach .

Contact Information

Name: Phone:
Email Address:

Business Information

Business Name: Business Address:
FEIN: Years in Business:
Description of Operations:

Current Auto Insurance Information

Company Name Policy Expiration
Premium Amount Term
Insurance
Carrier

Vehicle Information

(include all cars you or your family members own or lease)
Car #1
Year
Make
Model
Body Type
Use of Vehicle
Radius
GVW (Gross Vehicle Weight)
Value
Vehicle ID# (VIN)
Name of Title Holder
Driver Name
  Airbags  
Car Alarm
Y   N
Y   N
Car #2 (enter info)
Car #3 (enter info)
Car #4 (enter info)

Liability Limit

for ALL Cars
Choose either   Bodily Injury   and   Property Damage
or   Single Limit
Bodily Injury
        
Property Damage
Single Limit

The minimum auto liability coverage amount required by the states of Texas and Arkansas is $30,000 for each injured person, up to a total of $60,000 per accident, and $25,000 for property damage.

Other Coverages

Personal Injury Protection/Medical Payments
Uninsured/Underinsured Motorist - Bodily Injury
Uninsured/Underinsured Motorist - Property Damage
PIP With Workers Compensation

Texas and Arkansas insurers must offer you $2,500 in Personal Injury Protection, but you can buy more. Texas and Arkansas require insurance applicants to reject PIP coverage in writing if they don't want it.

Deductibles and Misc.

Car#
Comprehensive Deductible
Collision Deductible
Towing
Rental Reimbursement
1
Yes
Yes
2
Yes
Yes
3
Yes
Yes
4
Yes
Yes
Driver Information(include all licensed drivers in your company)

Driver #1

Driver's Name
Drivers License Information
DL#:
Date of Birth
Sex
Marital Status
Courses Completed Last 3 yrs
M
F
Married  Single
Drivers Ed: 
Defensive Driving;
Drug & Alcohol Awareness: 
Driver #2 (enter info)
Driver #3 (enter info)
Driver #4 (enter info)

Driver History

List ANY convictions for ANY driver convicted of moving traffic violations in the past 3 years
Driver
Date
Type of Conviction
Speed Over Limit
mph
mph
mph
mph
List ANY driver involved in accidents, regardless of fault, in the past 5 years
Driver
Date
Description
Cost
Injuries
At Fault
$
Yes
Yes
$
Yes
Yes
$
Yes
Yes
$ Yes Yes

Additional Comments



Please give any additional comments you feel appropriate for this quotation.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

Submission of quote request form to this agency does not constitute a binding confirmation of new or revised insurance coverage.

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