Auto Quote

To receive a Quote for Auto Insurance, please fill out the following form and click the "Request Quote" button at the bottom of the form to submit your information to John J. Prudente Agency.  One of our agents will contact you shortly.

You may use your tab key or your mouse to move through the form.

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?


If phone, best time to call:

Driver One

Name:
Date of Birth (mm/dd/yy):
Driver's License No.
State Issued:
Years Licensed:
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 #:

Driver Two (Optional)

Name:
Date of Birth (mm/dd/yy):
Driver's License No.
State Issued:
Years Licensed:
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 #:

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: 
Est. Annual Mileage:
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: 
Est. Annual Mileage:
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
Property Damage to Someone Else's Property
Bodily Injury to Others
Medical Payments
Collision
Comprehensive
Rental
Towing & Labor
Bodily Injury Caused by an Underinsured Driver
Account Credit Eligibility

Check all memberships that apply:
AAA  

I

Current Insurance Carrier:


Renewal Date:


 

Current Insurance Info
Who is your current 
insurance carrier?
(if applicable)

Renewal Date:




Check here if this 
is a new purchase:

Purchase Date:




   

 

 

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