| 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 |
|
|
Mandatory Coverages
|
Bodily Injury to
Others.
Massachusetts is a "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.
|
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.
|
Bodily Injury Caused by an Uninsured Auto.
This typically covers you for bodily injury to you or your
passengers by an uninsured vehicle.
|
Property Damage to Someone Else's Property.
This typically covers you for accidents causing damage to
another's property.
|
|
Optional Coverages
Please fill out this section if you want "optional" coverages.
Skip to Driver Section below if not interested. |
Bodily Injury to Others.
This is additional coverage for bodily injury to
others.
|
Medical Payments. This typically
covers injuries to you and your passengers, regardless of who's at fault.
|
|
Collision.
This
typically covers physical damage to your vehicle from an accident. |
|
Coverage...
|
Deductible...
|
|
Comprehensive.
This typically covers all other physical damage to your
vehicle (other than collision) including fire, theft, vandalism, and
glass. |
|
Coverage...
|
Deductible...
|
Rental.
This typically covers the cost to rent a vehicle while yours
is disabled.
|
Towing & Labor.
This typically covers towing and labor charges for your disabled vehicle.
|
Bodily Injury Caused by an Underinsured Driver.
This typically covers bodily injury to you or your passengers
by underinsured drivers.
|
|
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 |
|
|
How many years have you been
driving |
|
| Date of Birth:
Month Day
Year
|
|
|
