DRIVER INFORMATION

Your Full Name:

City Primarily Garaged:

State Licensed: Massachusetts Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Misissippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Washington D.C.

E-mail Address:

Zip Code:

Phone Number:

Best time to call:

Years of Driving Experience: 6 + 3 - 6 0 - 3

If less than 3 years, have you completed
a course in Driver Training? No Yes

Date first licensed:

Date of Birth:

Do you own an insurance policy?: Own Do not own

 If so, expiration date is:

I will purchase insurance within the next 30 60 90 other days.

Drivers License Number:

 

VEHICLE INFORMATION
Year	Make	Model

Please check all that apply to you and/or your vehicle.

 Airbags
 Automatic Seat belts
 Drive less than 5,000 miles per year
 Drive between 5,000 miles and 7,500 miles per year
 Purchased a monthly transit pass (at least 11 months)
 Antitheft device (Alarm)
 Vehicle Recovery System (LoJack)
 Over the age of 65

Personal Injury Protection:
$8,000  (Mandatory)

Bodily Injury caused by uninsured auto:
$20,000 per person / $40,000 per accident $25,000 per person / $50,000 per accident $35,000 per person / $80,000 per accident $50,000 per person / $100,000 per accident $100,000 per person / $300,000 per accident $250,000 per person / $500,000 per accident  

Damage to someone else's property:
$5,000 $10,000 $25,000 $50,000 $100,000  

Medical Payments:
No Coverage $5,000 per person $10,000 per person $15,000 per person $20,000 per person $25,000 per person  

Collision Coverage/ Deductible:
No Coverage $500 $300 $1000  

Comprehensive Coverage/Deductible:
No Coverage $500 $300 $1000  

Substitute Transportation:
No Coverage $15 per day $30 per day  

Towing and Labor:
No Coverage $25 per incident $50 per incident  

Bodily Injury caused by underinsured:
$20,000 per person / $40,000 per accident $25,000 per person / $50,000 per accident $35,000 per person / $80,000 per accident $50,000 per person / $100,000 per accident $100,000 per person / $300,000 per accident $250,000 per person / $500,000 per accident  

Have you had any at-fault accidents or moving violations in the past six (6) years?

No Yes  

If you have questions or comments about insuring your automobile in Massachusetts, or want to suggest ways for improving our web site, please state them here:

QUOTES ARE FOR MASSACHUSETTS ONLY!

*Enter Security Code: 8