Colonial Insurance Agency, Inc.
310 North Main St., Unit #6
Mansfield, MA 02048
(Tel) 800-571-7773 (Fax) 508-339-8991 |
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Auto Insurance Quote
(MNA)
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Please print this form and fax to (508) 339-8991
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Vehicle Information
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| City or Town where vehicle is principally garaged |
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| Make of vehicle (Chevy, Honda, etc.) |
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| Model of vehicle (Malibu, Accord, etc.) |
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| Body Style of vehicle (sedan, van, wagon, etc.) |
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| Year of vehicle |
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| Vehicle I.D. Number (VIN optional) |
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| Number of miles driven each year |
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| Airbags & Automatic Seatbelts |
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Mandatory Coverages
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Bodily Injury to Others. Mandatory - $20,000 per person & $40,000 per accident
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 . Go to the "Optional Coverage" section below if you want additional bodily injury coverage.
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Personal Injury Protection. Mandatory - $8,000 per person
This typically covers injuries to you and your passengers, regardless of who's at fault. This mandatory coverage is already selected for you. For additional coverage see optional "Medical Payment" coverage below.
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Bodily Injury Caused by
an Uninsured Auto. Mandatory Only ($20,000 / $40,000)
This typically covers you for bodily injury to you or your passengers by an uninsured vehicle. [circle one]
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$25,000 each person & $25,000 each accident
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$100,000 each person & $100,000 each accident |
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$50,000 each person & $50,000 each accident
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$250,000 each person & $250,000 each accident |
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Property Damage to Someone Else's
Property. Mandatory Only ($5,000)
This typically covers you for accidents causing damage to another's property. [circle one] |
Optional Coverages
Please circle you choices if you want "optional" coverages. Skip to Driver Section below if not interested.
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Bodily Injury to Others.
This is additional coverage for bodily injury to others. [circle one]
| No Coverage |
$100,000 each person & $300,000 each accident |
| $25,000 each person & $50,000 each accident |
$250,000 each person & $500,000 each accident |
| $50,000 each person & $100,000 each accident |
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Medical Payments. This typically covers injuries to you and your passengers, regardless of who's at fault.
[circle one]
| No Coverage |
$25,000 |
| $5000 |
Not Sure. Please Advise. |
| $10,000 |
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Collision.
This typically covers physical damage to your vehicle from an accident. [circle one] |
Coverage...
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No Coverage
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Book Value |
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Not Sure. Please Advise. |
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Deductible (Select one (if you chose coverage)
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$300 |
$1000 |
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$500 |
Not Sure. Please Advise. |
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Comprehensive. This typically covers all other physical damage to your vehicle (other than collision) including fire, theft, vandalism, and glass. [circle one] |
Coverage...
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No Coverage
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Book Value |
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Not Sure. Please Advise. |
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Deductible (Select one (if you chose coverage)
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$300 |
$1000 |
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$500 |
Not Sure. Please Advise. |
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Rental.
This typically covers the cost to rent a vehicle while yours is disabled. [circle one]
| No Coverage |
Up to $30 per day, $900 maximum |
| Up to $15 per day, $450 maximum |
Not Sure.
Please advise. |
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Towing & Labor.
This typically covers towing and labor charges for your disabled vehicle. [circle one]
| No Coverage |
Up to $50 per disablement |
| Up to $25 per disablement |
Not Sure.
Please advise. |
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Bodily Injury Caused by an Underinsured Driver.
This typically covers bodily injury to you or your passengers by underinsured drivers.. [circle one]
| No Coverage |
$50,000 each person & $100,000 each accident |
| $20,000 each person & $40,000 each accident |
$100,000 each person & $300,000 each accident |
| $25,000 each person & $50,000 each accident |
$250,000 each person & $500,000 each accident |
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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 |
| Driver's License Number: |
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Name: |
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E-mail: |
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| Address: |
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| City: |
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| State: |
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| Zip : |
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Phone: |
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Fax: |
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Write Comments, Questions or Additional Drivers below:
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