Step 1 - Personal Info
First Name:
Last Name:
Date of Birth:
(mm/dd/yyyy)
Day Phone:
Evening Phone:
E-Mail:
Street:
City:
State:
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New
Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Zip:
The best way to reach me is:
Daytime Phone
Evening Phone
E-Mail
Postal Mail
Step 2 - Additional Info
Driver's License #:
When were you first licensed?
(mm/dd/yyyy)
What state were you first licensed in?
Massachusetts
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New
Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Year of Vehicle:
Make:
Model:
V.I.N. # (if available)
Town of Garaging:
Years in Town?
Do you have home, apartment or condominium insurance? If yes, with which company?
Yes
No
Do you own a home?
Yes
No
Full time, Good Student? (B or better avg)
Yes
No
Are you a member of any of the following groups?
Select One...
St. Anselm Alumni
Mass Bar Association
Mass Medical Society
Mass Coalition of Police
State Police Association of Mass
Professional Fire Fighters of Massachusetts
In Control Advanced Driver Training
Boston College Alumni
Are you a member of AAA?
Yes
No
Anti-theft Device?
If yes explain type:
Yes
No
Estimated Annual Mileage?
Select One...
under 5,000
under 7,500
over 7,500
Current Company:
Renewal Date:
(mm/dd/yyyy)
Step 3 - Coverage Selections
Physical Damage Coverage (Covers the value of your vehicle if you are at fault in an accident, a victim of a hit & run or if your vehicle suffers fire, theft, or vandalism.)
NO COLLISION COVERAGE / NO COMPREHENSIVE COVERAGE - Due to the age & (lack of) value of my vehicle
$300 DEDUCTIBLES - COLLISION & COMPREHENSIVE COVERAGE.
$500 DEDUCTIBLES - COLLISION & COMPREHENSIVE COVERAGE.
$1000 DEDUCTIBLES - COLLISION & COMPREHENSIVE COVERAGE.
Choose your Liability Limits:
Minimum-type Liability Limits
$20,000 per person/ $40,000 per accident Bodily Injury &
Uninsured/Underinsured Motorist Protection
$100,000 Property Damage
Basic Protection
$50,000 per person/ $100,000 per accident Bodily Injury &
Uninsured/Underinsured Motorist Protection
$100,000 Property Damage
Recommended Limits (at least)
$100,000 per person/ $300,000 per accident Bodily Injury &
Uninsured/Underinsured Motorist Protection
$100,000 Property Damage
Superb Protection*
$250,000 per person/$500,000 per accident Bodily Injury &
Uninsured/Underinsured Motorist Protection
$100,000 Property Damage
*Many people that choose Superb Protection are also interested in
carrying a Personal Liability Umbrella Policy. These limits are the
underlying requirements for a Personal Liability Umbrella Policy.
Additional Comments or Information:
Thank you for your info. A professional, independent, full service insurance broker will be in touch with you when and where you requested.