Phone number Fax number
Email address
License number
Date of birth
Year make and model of vehicles. Please include plate #’s and/or vin #’s
1)Year/Make/plate or vin # Odometer Alarm: no yes 2)Year/Make/plate or vin # Odometer Alarm: no yes 3)Year/Make/plate or vin # Odometer Alarm: no yes 4)Year/Make/plate or vin # Odometer Alarm: no yes How many drivers in the household (other than insured)? 1) Name License Date of birth Vehicle driven most often 2) Name License Date of birth Vehicle driven most often 3) Name License Date of birth Vehicle driven most often 4) Name License Date of birth Vehicle driven most often Any other “regular” operators? no yes 1 ) Name License Date of birth Vehicle driven most often Can any driver be deferred to another Massachusetts auto policy? no yes If yes, please name the driver(s) and company they are insured with. Please name any driver currently enrolled at a high school or college. Do they maintain a “B” or better? (proof will be required if discount applies). no yes Are they currently residing at school? no yes If yes, please provide city and state: City State Do you have any other policy with any of these carriers: None NGM PRAC N&D Encompass If yes, what type of policy: None Home Owners Policy Business Policy Please select coverage limits: Limits of liability: 35/80 50/100 100/300 250/500 500/500 Medical Payments: no yes If yes, please choose amount: 0 5000 10000 25000 Vehicle 1: Full Collision: no yes If yes, choose deductible: 0 300 500 1000 Limited Collision: no yes Comprehensive (fire & theft) no yes If yes, choose deductible: 0 300 500 1000 Is there a lein on any vehicle? no yes Is it leased? no yes Rental 0 15 30 45 100 Towing: 0 50 100 Vehicle 2: Full Collision: no yes If yes, choose deductible: 0 300 500 1000 Limited Collision: no yes Comprehensive (fire & theft) no yes If yes, choose deductible: 0 300 500 1000 Is there a lein on any vehicle? no yes Is it leased? no yes Rental 0 15 30 45 100 Towing: 0 50 100 Vehicle 3: Full Collision: no yes If yes, choose deductible: 0 300 500 1000 Limited Collision: no yes Comprehensive (fire & theft) no yes If yes, choose deductible: 0 300 500 1000 Is there a lein on any vehicle? no yes Is it leased? no yes Rental 0 15 30 45 100 Towing: 0 50 100 Vehicle 4: Full Collision: no yes If yes, choose deductible: 0 300 500 1000 Limited Collision: no yes Comprehensive (fire & theft) no yes If yes, choose deductible: 0 300 500 1000 Is there a lein on any vehicle? no yes Is it leased? no yes Rental 0 15 30 45 100 Towing: 0 50 100 Name of current company: Renewal date: Do you owe any outstanding premium to another insurance company? no yes Please check off any additional coverage you may be interested in: Accident Forgiveness Disappearing deductible or deductible reduction New Vehicle Replacement Coverage Original Equipment Manufacturer Part Personal Clothing Coverage Loan/Lease GAP Coverage Trip Interruption Roadside Assistance Pet Injury Please add any additional remarks or questions. ________________________________________________________________________________________________________________ We will match you with a company who will offer you the most competitive rate with the coverage you desire. By submitting this form you are authorizing us to verify your information through the RMV. Please allow us 24 (business) hours to complete your request.
2) Name License Date of birth Vehicle driven most often
3) Name License Date of birth Vehicle driven most often
4) Name License Date of birth Vehicle driven most often
Any other “regular” operators? no yes 1 ) Name License Date of birth Vehicle driven most often
Can any driver be deferred to another Massachusetts auto policy? no yes If yes, please name the driver(s) and company they are insured with.
Please name any driver currently enrolled at a high school or college.
Do they maintain a “B” or better? (proof will be required if discount applies). no yes
Are they currently residing at school? no yes
If yes, please provide city and state: City State
Do you have any other policy with any of these carriers: None NGM PRAC N&D Encompass
If yes, what type of policy: None Home Owners Policy Business Policy
Please select coverage limits: Limits of liability: 35/80 50/100 100/300 250/500 500/500
Medical Payments: no yes If yes, please choose amount: 0 5000 10000 25000
Vehicle 1: Full Collision: no yes If yes, choose deductible: 0 300 500 1000
Limited Collision: no yes Comprehensive (fire & theft) no yes If yes, choose deductible: 0 300 500 1000 Is there a lein on any vehicle? no yes Is it leased? no yes Rental 0 15 30 45 100 Towing: 0 50 100
Vehicle 2: Full Collision: no yes If yes, choose deductible: 0 300 500 1000
Vehicle 3: Full Collision: no yes If yes, choose deductible: 0 300 500 1000
Vehicle 4: Full Collision: no yes If yes, choose deductible: 0 300 500 1000 Limited Collision: no yes Comprehensive (fire & theft) no yes If yes, choose deductible: 0 300 500 1000 Is there a lein on any vehicle? no yes Is it leased? no yes Rental 0 15 30 45 100 Towing: 0 50 100
Name of current company:
Renewal date:
Do you owe any outstanding premium to another insurance company? no yes
Please check off any additional coverage you may be interested in: Accident Forgiveness Disappearing deductible or deductible reduction New Vehicle Replacement Coverage Original Equipment Manufacturer Part Personal Clothing Coverage Loan/Lease GAP Coverage Trip Interruption Roadside Assistance Pet Injury
Please add any additional remarks or questions.
________________________________________________________________________________________________________________ We will match you with a company who will offer you the most competitive rate with the coverage you desire.
By submitting this form you are authorizing us to verify your information through the RMV. Please allow us 24 (business) hours to complete your request.
