Name              Required

E-mail address        Required

Address           

City                 Required

State                 Massachusetts Residents Only

Phone              Fax 

Please describe your vehicle

Vehicle #1 Required

YR    Make   Model  

 Alarm yes  no  if yes type  

Miles driven each year  over 10,000 between 5000 & 7500 less then 5000

Vehicle # 2 if necessary

YR    Make   Model  

 Alarm yes  no  if yes type

Miles driven each year  over 10,000 between 5000 & 7500 less then 5000

Vehicle # 3 if necessary

YR    Make   Model  

 Alarm yes  no  if yes type

Miles driven each year  over 10,000 between 5000 & 7500 less then 5000

Coverages:

Part 3 Uninsured Motorist              100,000/300,000 20,000/40/000 25,000/50,000 30,000/70,000 50,000/100,000 250,000/500,000 500,000/500,000 500,000/1,000,000 Must be equal or less than part 5

Part 4 Property Damage              5,000 10,000 25,000 50,000 100,000 250,000

Part 5 Bodily Injury                    100,000/300,000 20,000/40,000 20,000/50,000 25,000/50,000 30,000/70,000 50,000/100,000 250,000/500,000 500,000/500,000 500,000/1,000,000

Part 6 Medical Payments              none 5,000 10,000 15,000 20,000 25,000 50,000 100,000

Part 7 Collision Deductible            500 300 1,000 2,000

Part 9 Comprehensive Deductible    300 500 1,000 2,000  

Part 10 Substitute Transportation     15 a day / 450 max 30 a day / 900 max 45 a day / 1350 max 100 a day / 3,000 max none

Part 11 Towing                          50 per disablement 100 per disablement none

Part 12 Underinsured Motorist        100,000 / 300,000 20,000 / 40,000 20,000 / 50,000 25,000 / 50,000 50,000 / 100,000 250,000 / 500,000 500,000 / 500,000 500,000 / 1,000,000   Must be equal or less than part 5

Driver Information:

Please list all household members who will operate the vehicles

Driver name DOB license #       SDIP step

Driver name DOB license #       SDIP step

Driver name DOB license #       SDIP step

Driver name DOB license #       SDIP step

Are you a member of any automobile Club?  yes  no  name of club

Comments

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