Please fill ot this simple form to get your Auto Insurance Quote.
For a quote by phone call 781 894-8500 and ask for Mark at ext. 231
Have you been cancelled for non-payment of premium by a Masachusetts auto insurance company in the last 24 months? Yes   No
Do you need an SR-22 form? Yes   No
Are you looking for a Motorcycle Policy? Yes   No
Do you currently have an active/in force
Massachusetts auto policy and are
shopping this site for a better price?		Yes   No
When will you be ready
to purchase the policy?		 ASAP     Within 7 Days    Over 7 Days
Which best describes
your current car situation?
Which best describes
your current living situation?		 Rent     Own    Live With Parents
Will this be your first
Massachusetts auto insurance policy?		 Yes   No
 
Step 1 - Personal Info: Required Fields are in RED
First Name
Last Name
Day Phone
Evening Phone
E-Mail *instant email when completed
Street
City
State
Zip
Step 2 - Driver Information: Driver 1 Driver 2
First Name
Last Name
Date of Birth
How long have you been driving?
Date First Licensed
Sex: Male   Female Male   Female
Marital Status: Single   Married Single   Married
Driver’s License #
License State
Were you licensed in
another country?		 Yes   No Yes   No
If Yes, What country?
For How Many Years?
Can you provide proof
of a clean driving record
from your country?		 Yes   No Yes   No
Accidents At Fault
In last 6 Years
Moving Violations
In last 6 Years
Have you completed a
Driver Education Course?		 Yes   No Yes   No
Have you completed an
Advanced Driver
Education Course?		 Yes   No Yes   No
Are you a student
with a B average or better?		 Yes   No Yes   No
Do you have a child
away at school?		 Yes   No Yes   No
How many cars do you own?
Do you belong to a motor club? Yes   No Yes   No
Do you drive a hybrid? Yes   No Yes   No
Name of current Insurance Co:
Years with current Insurance Co:
When does your current policy expire/renew?
Current annual premium?
Step 3 - Vehicle Info: Vehicle 1 Vehicle 2Vehicle 3
Year of Vehicle
Make
Model
VIN # (if available)
Estimated Annual mileage
Current Odometer Reading
Town car is parked in at night.
Anti-theft device Yes   No Yes   No Yes   No
Lo-Jack Yes   No Yes   No Yes   No
Step 3 -Coverage Selections:
MA minimum liability limits on parts 3, 5 and 12 are 20,000 per person/$40,000 per accident.
We recommend $100,000 per person/$300,000 per accident. Please select your desired coverage.
Part 1 Compulsory, Bodily Injury to Others $20,000 per person/$40,000 per accident $20,000 per person/$40,000 per accident $20,000 per person/$40,000 per accident
Part 2 Personal Injury Protection
($8,000 Deductible)		 $0 Deductible $0 Deductible $0 Deductible
Part 3, Uninsured Motorist Protection
Part 4, Property Damage
Part 5, Optional Bodily Injury to Others
Liability
Part 6, Medical Payments Coverage
Part 7, Collision (Deductibles)
Part 8, Limited Collision (Deductibles)
Part 9, Comprehensive (Deductibles)
Part 10, Substitute Transportation
Coverage
Part 11, Towing & Labor
Part 12, Underinsured Motorist Protection
Additional Comments or Information
 


 
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