Massachusetts Auto Quote Form

The purpose of this form is to acquire all the information necessary to accurately quote a Massachusetts auto policy. There is no information requested here that is unnecessary in order for you to get the most accurate quote!!

Please provide the following information:

Name

Contact Phone

E-mail

Drivers License Number (required)

*Year of Car 1*
*Make & Model of car*
Town where car is garaged:

Are there any other regular drivers of this car? Yes No

If there are any other household members, or other regular operators of the vehicle, they must be listed here, even if they have their own policy.

Driver 2 License #	Do they have their own policy? Yes No
Driver 3 License #	Do they have their own policy? Yes No
Driver 4 License #	Do they have their own policy? Yes No

Part	Coverage	Limit Vehicle One
1	Bodily Injury to others (required)	20,000 / 40,000
2	Personal Injury Protection	8000 per person (Compulsory)
3	Uninsured Motorist Coverage
4	Property Damage to Others
5	Optional Bodily Injury to others
6	Medical payments
7	Collision	Deductible
8	Limited Collision	Deductible
9	Comprehensive	Deductible
10	Substitute Transportation
11	Towing and Labor
12	Underinsured Motorist

Annual Mileage: Anti-theft device:

Yes

or enter additional information:

Information for second car on policy:

*Year of Car* 2
*Make & Model of car*
Town where car is garaged:

Part	Coverage	Limit Vehicle Two
1	Bodily Injury to others (required)	20,000 / 40,000
2	Personal Injury Protection	8000 per person (Compulsory)
3	Uninsured Motorist Coverage
4	Property Damage to Others
5	Optional Bodily Injury to others
6	Medical payments
7	Collision	Deductible
8	Limited Collision	Deductible
9	Comprehensive	Deductible
10	Substitute Transportation
11	Towing and Labor
12	Underinsured Motorist

Annual Mileage: Anti-theft device:

Yes

or enter additional information:

Please give any additional information here:

Name
Contact Phone
E-mail
Drivers License Number	(required)