IMPORTANT – PLEASE READ BEFORE COMPLETING
Please note that by submitting this form you understand that coverage is not bound and no policy is issued or in effect. This information is for quoting purpose only. Coverage cannot be bound until such time as we submit a formal application to you and it is signed and returned to our office along with the appropriate down payment. All information submitted is held in the strictest confidence and is only used for the purposes of providing you an insurance quote.
To provide an accurate quote, please complete all questions as listed below.
MASSACHUSETTS AUTOMOBILE QUOTE
Current Address is: Owned Rented Live with family
Do you currently have insurance on your vehicle: Yes No
If yes please provide your current insurance company Expiration date of your current policy:
VEHICLE INFORMATION
No of Vehicles to Quote 1 2 3 4
Year* Make* Model*
VIN#*
How is the vehicle used? Personal Use Only Business Use
If business use please describe the type of business:
Place of principal Garaging:
Name of principle operator:
Select the coverage and limits desired:
Compulsory Insurance Parts 1 - 4
Part 1 Bodily injury to Others $20,000 Per Person $40,000 Per Accident see Coverage
Part 1: Bodily injury to others pays for damages (e.g. medical expenses, pain and suffering to anyone injured or killed by your care only in an accident that occurs in Massachusetts up to the basic limits of $20,000 per Person $40,000 per accident. Injuries to the driver or passengers in your care are NOT covered under this part. Please refer to Part 2 Personal Injury Protection and Part 5 Optional Bodily Injury for information about that coverage.
Part 2. Personal Injury Protection $8,000 Per Person see Coverage
Part 2: Personal Injury Protection (PIP) pays up to $8000 to you or anyone you let drive your car, anyone living in your household, passengers and pedestrians, no matter who causes the accident. Personal Injury Protection pays for Medical expenses, replacement services and 75% of any lost wages.
Your PIP coverage pays for medical expenses in excess of $2,000 that are not paid for by your medical insurance only after these expenses have been submitted to the medical insurer to determine what it will and will not pay. Your PIP coverage will NOT pay for expenses over $2,000 that your medical insurer would have paid if the injured person had sought treatment in accordance with the terms of your health plan.
Part 3. Uninsured Choose one $20,000 Per Person/ $40,000 Per Accident $20,000 Per Person/ $50,000 Per Accident $25,000 Per Person/ $50,000 Per Accident $35,000 Per Person/ $80,000 Per Accident $50,000 Per Person/ $100,000 Per Accident $100,000 Per Person/ $300,000 Per Accident $250,000 Per Person/ $500,000 Per Accident $500,000 Per Person/ $500,000 Per Accident $500,000 Per Person/ $1,000,000 Per Accident see Coverage
Part 3: Bodily injury caused by an uninsured auto protects you, anyone you let drive your car, household members and passengers, (unless covered by another Massachusetts policy with similar coverage) against losses caused by an uninsured or unidentified (“hit and run”) driver. A minimum limit of $20,000 per person and $40,000 per accident is required. This coverage does not pay for property damage or damage to your auto.
Part 4. Property Damage Choose one $5,000 Damage to someone Else's Property $10,000 Damage to someone Else's Property $25,000 Damage to someone Else's Property $50,000 Damage to someone Else's Property $100,000 Damage to someone Else's Property see Coverage
Part 4: Damage to someone Else’s Property – This coverage pays for damage to another person’s property and costs associated with the loss of use of that property, when you. A household member or another authorized driver causes an accident. A minimum limit of $5,000 is required.
Optional Insurance Parts 5-12
Part 5 Optional Bodily Injury Choose one $20,000 Per Person/ $40,000 Per Accident $20,000 Per Person/ $50,000 Per Accident $25,000 Per Person/ $50,000 Per Accident $35,000 Per Person/ $80,000 Per Accident $50,000 Per Person/ $100,000 Per Accident $100,000 Per Person/ $300,000 Per Accident $250,000 Per Person/ $500,000 Per Accident $500,000 Per Person/ $500,000 Per Accident $500,000 Per Person/ $1,000,000 Per Accident see Coverage
Part 5: Optional Bodily Injury to Others extends you liability protection (the basic $20,000/$40,000 limits under Part 1 Bodily Injury to others) up to the amount you purchase under this part. This option provides coverage for accidents beyond Massachusetts to anywhere in the United States, its territories or possessions or Canada. This coverage also pays for damages suffered by guest in you automobile.
Part 6 Medical Payments Choose one $5,000 Per Person $10,000 Per Person $15,000 Per Person $20,000 Per Person $25,000 Per Person $50,000 Per Person $100,000 Per Person see Coverage
Part 6: Medical Payments covers medical expenses for you, your household members and passengers, over and above amounts covered by Personal Injury Protection (PIP) no matter who caused the accident. The minimum amount you can by is $5000 if insuring an automobile or $500 if insuring a motorcycle.
Part 7. Collision Choose one $300 Deductible (standard) $500 Deductible $1000 Deductible $2000 Deductible see Coverage
Part 7: Collision Coverage pays for damage to your car, less any applicable deductible, no matter who causes the accident. If your car is financed, your lender may require this coverage as well as a particular deductible amount. This coverage provides Actual Cash Value (Book Value).
Part 9. Comprehensive Choose one $300 Deductible (standard) $500 Deductible $1000 Deductible $2000 Deductible see Coverage
Part 9: Comprehensive Coverage pays for damage to or loss of your car, less any applicable deductible, resulting from perils such as fire, theft, vandalism, and striking an animal, but NOT Collision. This coverage allows up to $15 per day (to a limit of $450) for substitute transportation (rental or other transportation costs including taxi, bus and train fare) until your stolen auto is recovered. Personal property is not covered unless it is permanently installed in your car, such as a stereo. If your car is financed, your lender may require this coverage.
Part 10 Substitute Transportation Choose one $15 per Day/ $450 Maximum $30 per Day/ $900 Maximum $45 per Day/ $1,350 Maximum $100 per Day/ $3,000 Maximum see Coverage
Part 10: Substitute Transportation reimburses up to $15 a day for car rental or Transportation costs including taxi, bus, and train fare (up to $450) while your car is undergoing collision or covered repairs. Coverage of up to $100 a day (up to a limit of $3,000) is available for an additional cost. Even if you have this coverage, some car rental agencies may refuse to rent to you if you are under a certain age, a poor credit risk, do not have an acceptable credit card or have an unacceptable driving record.
Part 11. Towing Choose one $50 Per Claim $100 Per Claim see Coverage
Part 11: Towing and labor coverage pays up to $50 for towing and labor charges each time your car breaks down whether or not there is an accident involved. You are covered only for the on site labor costs at the breakdown site (not any parts) needed to get your car running again. Coverage up to $100 per disablement is available for additional cost.
Part 12. Underinsured Auto Choose one $20,000 Per Person/ $40,000 Per Accident $20,000 Per Person/ $50,000 Per Accident $25,000 Per Person/ $50,000 Per Accident $35,000 Per Person/ $80,000 Per Accident $50,000 Per Person/ $100,000 Per Accident $100,000 Per Person/ $300,000 Per Accident $250,000 Per Person/ $500,000 Per Accident $500,000 Per Person/ $500,000 Per Accident $500,000 Per Person/ $1,000,000 Per Accident see Coverage
Part 12: Bodily Injury Caused by an Underinsured Auto pays for bodily injury damages to you, household members and passengers, unless they have a policy of their own, or are covered by a Massachusetts auto policy of another household member with similar coverage. The accident must be caused by someone without enough bodily injury coverage. It pays you up to the difference between the total amount collected from the bodily injury liability insurance covering the owner and driver of the other car, and the limits you purchase for this coverage.
Please check the following that apply:
Air Bags
Anti-Theft Device
Low Mileage discount 0 to 5000 miles per year 5000 to 7500 mile per year
Senior citizen – 65 years or older
Multi Car Discount – Insuring 2 or more vehicles with the same company.
Public Transit Discount – Must have 11 monthly passes.
No of Drivers 1 2 3 4
DRIVER INFORMATION
Please note that all household member must be listed or coverage could be limited or denied in the event of a claim.
DRIVER 1
Name:
Social Security Number:
Drivers License Number * (if different from Social Security Number):
Date of Birth
Marital Status: Married Single Divorced Widowed
DRIVER 2
DRIVER 3
DRIVER 4
Please use the space below to add any additional comments or concerns:
293 Bedford Street, PO Box 228, Whitman, MA 02382 781-447-5561 Fax: 781-447-1246 236 Quincy Ave, E. Braintree, MA 02184 781-848-4400 Fax: 781-843-0651 info@myinsuranceman.com