Name: *
Street: *
City: *
State: *
Zip Code: *
Email Address *
Phone: *		Home    Business    Cell

Phone:   Time: Choose Time Mornings Afternoons Early Evenings  or Email:

City Primarily Garaged: *
Years of Driving Experience: *		6+    3-6    0-3

Yes    No

Date First Licensed: *
Date of Birth: *
Do you own an insurance policy? *		Yes    No
If so, expiration date is:
Drivers License Number: *
Year of auto : *
Make/Model: *
Annual mileage: *
Business Use: *		Yes    No
If yes, describe business use (i.e. Carpentry):

		Air bags and/or Automatic Seatbelts
		Anti-Theft Device
		Vehicle Recovery System
		Over age 65
		AAA Membership
		Multi Car (more than one auto with same company)

The Massachusetts automobile insurance policy has twelve (12) parts. Parts 1 - 4 are mandatory, while Parts 5 - 12 are optional. (Part 5, however, is highly recommended.)

$20,000 per person/$40,000 per accident

$8,000 per person

PART 3 -- Uninsured Motorist (UM)  — more info

-- Select -- $250,000 per person/$500,000 per accident $100,000 per person/$300,000 per accident $50,000 per person/$100,000 per accident $35,000 per person/$80,000 per accident $25000 per person/$50,000 per accident $20,000 per person/$40,000 per accident Unsure, let’s discuss Higher amount, let’s discuss

PART 4 -- Property Damage (PD)  — more info

-- Select -- $100,000 $50,000 $25,000 $10,000 $5,000 Unsure, let’s discuss Higher amount, let’s discuss

PART 5 -- Bodily Injury to Others (extra-territorial coverage)  — more info

-- Select -- $250,000 per person/$500,000 per accident $100,000 per person/$300,000 per accident $50,000 per person/$100,000 per accident $35,000 per person/$80,000 per accident $25,000 per person/$50,000 per accident $20,000 per person/$40,000 per accident Unsure, let’s discuss Higher amount, let’s discuss

PART 6 -- Medical Payments  — more info

-- Select -- $25,000 $20,000 $15,000 $10,000 $5,000

PART 7 - Collision  — more info

-- Select -- $300 Deductible $500 Deductible $1000 Deductible $2000 Deductible

PART 8 -- Limited Collision  — more info

-- Select -- $0 Deductible $300 Deductible $500 Deductible $1000 Deductible $2000 Deductible

PART 9 - Comprehensive  — more info

-- Select -- $300 Deductible $500 Deductible $1000 Deductible $2000 Deductible

PART 10 -- Substitute Transportation  — more info

-- Select -- $15/Day, $450 Maximum $30/Day, $900 Maximum $45/Day, $1350 Maximum $100/Day, $3,000 Maximum

PART 11 -- Towing and Labor  — more info

-- Select -- $50 per Disablement $100 per Disablement

PART 12 -- Underinsured Motorist (UIM)  — more info

-- Select -- $250,000 per person/$500,000 per accident $100,000 per person/$300,000 per accident $50,000 per person/$100,000 per accident $35,000 per person/$80,000 per accident $25,000 per person/$50,000 per accident $20,000 per person/$40,000 per accident Unsure, let’s discuss Higher amount, let’s discuss

		-- Select -- Article in industry publication Advertisement (print) Yellow Pages Banner Ads Direct Mail Internet Search Newspaper Public Relations Web Site Link Word of Mouth
Other:

Yes    No