Contact
Information
Name:
Mail Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Fax:
E-Mail:
MA city or town where vehicle (s) is
principally garaged:
What is your preferred
form of contact to receive your quote? Home Phone Work
Phone Fax Email Mail If phone, best time to
call:
Driver
One
Name:
Date of Birth (mm/dd/yy) :
Driver's License No.
State Issued:
Years Licensed:
Less than 3 years
3-6 years Over 6 years
Driver training class?
Yes No
Have you been incident free (no
at-fault accidents, moving violations or citations) for the last six
years?
Yes
No
If yes, check the appropriate box:
I have
been licensed in MA for at least 6 years I am not presently
licensed in MA Licensed in MA < six
years, but previously licensed in another state:
MA Safe Driver Insurance Plan Step
#:
99
98
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Driver
Two (Optional)
Name:
Date of Birth (mm/dd/yy) :
Driver's License No.
State Issued:
Years Licensed:
Less than 3 years 3-6
years Over 6
years
Driver training class?
Yes No
Have you been incident free (no
at-fault accidents, moving violations or citations) for the last six
years?
Yes No
If yes, check the appropriate box:
I have been licensed in MA for at least
6 years I am not presently licensed in MA Licensed in MA < six
years, but previously licensed in another state:
MA Safe Driver Insurance Plan Step
#:
99
98
0
1
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Vehicle
One
Make of vehicle: (Ford, Toyota, etc.)
Model of vehicle: (Taurus, Camry, etc.)
Body Style of vehicle: (wagon, sedan, van,
etc.)
Year of vehicle:
Usage:
Pleasure Work
Anti-Theft device:
None Factory Installed
Security System Lo-Jack Vehicle Recovery
System
Est. Annual Mileage:
0-5000 miles per
year 5001-7500
miles per year Over 7501 miles per
year
Vehicle Identification No.:
Vehicle
Two (Optional)
Make of vehicle: (Ford, Toyota, etc.)
Model of vehicle: (Taurus, Camry, etc.)
Body Style of vehicle: (wagon, sedan, van,
etc.)
Year of vehicle:
Usage:
Pleasure Work
Anti-Theft device:
None
Factory
Installed Security System Lo-Jack Vehicle Recovery
System
Est. Annual Mileage:
0-5000 miles per
year 5001-7500
miles per year Over 7501 miles per
year
Vehicle Identification No.:
Coverage
For more information about the
Coverages listed below, see the Auto
Insurance Buyer's Guide. (opens in a new
window)
Bodily Injury Caused by an Uninsured
Auto
Mandatory Only
($20,000 / $40,000) $25,000
each person & $50,000 each accident $50,000
each person & $100,000 each accident $100,000
each person & $300,000 each accident $250,000
each person & $500,000 each
accident
Property Damage to Someone Else's
Property
Mandatory Only
($5,000) $10,000 $25,000 $50,000 $100,000 Unsure, let's discuss
Higher amount, let's
discuss
Bodily Injury to Others
No Coverage $25,000
each person & $50,000 each accident $50,000
each person and & 100,000 each accident $100,000
each person & $300,000 each accident $250,000
each person & $500,000 each accident Unsure, let's discuss
Higher amount, let's
discuss
Medical Payments
No
Coverage $5,000 $10,000 $25,000 Unsure, let's discuss
Higher amount, let's
discuss
Collision
No
Coverage 300 500 1000
Comprehensive
No
Coverage 300 500 1000
Rental
No Coverage Up to $15 per day, $450
maximum Up to $30 per day, $900
maximum Unsure,
let's discuss
Towing & Labor
No Coverage Up to $25 per
disablement Up
to $50 per disablement Unsure, let's
discuss
Bodily Injury Caused by an Underinsured
Driver
No
Coverage $20,000
each person & $40,000 each accident $25,000
each person & $50,000 each accident $50,000
each person & $100,000 each accident $100,000
each person & $300,000 each accident $250,000
each person & $500,000 each accident Unsure, let's discuss
Higher amount, let's
discuss
Account Credit
Eligibility
Check all memberships that apply:
AAA
I own
my own home own my own
condo rent an
apartment or house Current Insurance Carrier: Renewal Date:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Current Insurance
Info
Who is your current insurance
carrier? (if applicable) Renewal Date:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Check here if this is a new
purchase: Purchase Date:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2008
2009
2010
2011
2012
2013
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2015
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2018
2019
2020