Curley Insurance Agency, Inc

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996 Main Street
Millis, MA 02054
Business: (508) 376-4377
Toll Free: (800) 513-4377
Fax: 508-376-2538
Email: william.t.curley@verizon.net


ONLINE AUTO QUOTE FORM

DRIVER INFORMATION

Your Full Name:

City Primarily Garaged:

State Licensed:

E-mail Address:

Zip Code:

Phone Number:

Best time to call:

Years of Driving Experience:

If less than 3 years, have you completed
a course in Driver Training?

Date first licensed:

Date of Birth:

Do you own an insurance policy?:

 If so, expiration date is:

I will purchase insurance within the next 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

Bodily Injury To Others:
 

Personal Injury Protection:
 
(Mandatory)

Bodily Injury caused by uninsured auto:
 

Damage to someone else's property:
 

Medical Payments:
 

Collision Coverage/ Deductible:
 

Comprehensive Coverage/Deductible:
 

Substitute Transportation:
 

Towing and Labor:
 

Bodily Injury caused by underinsured:
 

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

 

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!

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Building Curley Insurance Agency, Inc. – Offering auto insurance, home insurance, business insurance, and life insurance in the areas of Millis, Medfield, Sherborn, Holliston, Medway, Norfolk, Wrentham, and Franklin, Massachusetts. Representing the Commerce, Plymouth Rock Assurance, Bunker Hill, and Merchants Insurance Group.

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