Are you a member of the MNA or MARN?
select yes or no
yes
no
City or Town where
vehicle is principally garaged
Make of vehicle (Chevy, Honda, etc.)
Model of vehicle (Malibu, Accord, etc.)
Body Style of
vehicle (sedan, van, wagon, etc.)
Year of vehicle
Vehicle I.D.
Number (VIN optional)
Number of miles driven each
year
Number of Doors
Number of Airbags
Automatic Seat Belt
select yes or no
yes
no
Mandatory Coverages
Bodily Injury to
Others.
split limit " state. Mandatory bodily
injury coverage in Massachusetts is "20/40". That simply means if you get
in an accident and hurt someone, you are covered up to $20,000 for bodily
injury to each person and $40,000 for all bodily injury
per accident. This mandatory coverage is already selected for you
in the following box. Go to the "Optional Coverage" section below
if you want additional bodily injury coverage.
Mandatory - $20,000 per person & $40,000 per accident
Personal Injury
Protection. This
typically covers injuries to you and your passengers, regardless of who's
at fault. This mandatory coverage is already selected for you in
the following box. For additional coverage see optional "Medical
Payment" coverage below.
Mandatory - $8,000
per person
Bodily Injury Caused by an Uninsured Auto.
This typically covers you for bodily injury to you or your
passengers by an uninsured vehicle.
Mandatory Only
($20,000 / $40,000)
$25,000 each
person & $50,000 each accident
$50,000
each person & $100,000 each accident
$100,000
each person & $300,000 each accident
$250,000
each person & $500,000 each accident
Not sure. Please advise.
Property Damage to Someone Else's Property.
Mandatory Only ($5,000)
$10,000
$25,000
$50,000
$100,000
Not sure. Please advise.
Optional Coverages optional " coverages.Skip to Driver Section below if not interested.
Bodily Injury to Others.
additional coverage for bodily injury to
others.
No Coverage
$25,000 each
person & $50,000 each accident
$50,000
each person and & 100,000 each accident
$100,000
each person & $300,000 each accident
$250,000
each person & $500,000 each accident
Not sure. Please advise.
Medical Payments. This typically
covers injuries to you and your passengers, regardless of who's at fault.
No Coverage
$5,000
$10,000
$25,000
Not sure. PLease advise.
Collision.
This
typically covers physical damage to your vehicle from an accident.
Coverage...
No Coverage
Book Value
Not sure. PLease advise.
Deductible...
Select
one (if you chose coverage)...
$300
$500
$1,000
Not sure. PLease advise.
Comprehensive.
Coverage...
No Coverage
Book Value
Not sure. Please advise.
Deductible...
Select
one (if you chose coverage)...
$300
$500
$1,000
Not sure. PLease advise.
Rental.
No Coverage
Up to $15 per day, $450
maximum
Up to $30 per day, $900
maximum
Not sure. PLease advise.
Towing & Labor.
This typically covers towing and labor charges for your disabled vehicle.
No Coverage
Up to $25 per disablement
Up to $50 per disablement
Not sure. Please advise.
Bodily Injury Caused by an Underinsured Driver.
This typically covers bodily injury to you or your passengers
by underinsured drivers.
No Coverage
$20,000 each
person & $40,000 each accident
$25,000 each
person & $50,000 each accident
$50,000
each person & $100,000 each accident
$100,000
each person & $300,000 each accident
$250,000
each person & $500,000 each accident
Not Sure. Please advise.
Driver Information
Please fill out information on the driver. If
more than one driver is to be listed, please use the "Comments "
box below to provide the additional information.
Have you taken a driver training
class
Select one
yes
no
How many years have you been
driving
Date of Birth:
Month
