The Burtnett Agency LLC
600 East Penn Street Bedford, PA 15522
(814) 623-8419
Whatever your insurance needs may be,
call The Burtnett Agency
.
2nd Rider Information if needed
Your name:
Name:
Your Address:
Address:
Birth Date:
Birth Date:
Drivers License #:
Drivers License #:
Your email address:
Current Insurer:
Your phone number:
Cycle-ATV Information
Vin #:
Vin #:
Year:
Year:
Make:
Make:
Model:
Model:
Value:
Value:
Comp Ded:
Comp Ded:
Collision Ded:
Collision Ded:
Coverage Information
Bodily Injury Liability:
Property Liability:
Medical Benefits:
Work Loss Benefits:
Accidental Death:
Funeral Benefits:
UM/UIM Coverage:
Please submit your information and we
will get back to you as soon as
possible with your Cycle/ATV quote.