AMERICAN INSURANCE AGENCY

Auto Insurance Quote Form

 
Please complete the following form for a FREE MASSACHUSETTS ONLY quote.

Name

 

Address

City

State

Zip Code

County

Telephone Number

Fax Number

E-Mail Address

Vehicle Description

 
Vehicle #1 (Year, Make & Model)
Vehicle #2 (Year, Make & Model)

Vehicle Use

Vehicle #1 Pleasure > Driven to work - Under 3 miles one way >Driven to work - Under 10 miles one way >Driven to work - Over 10 miles one way >Business Use >
Vehicle #2 Pleasure > Driven to work - Under 3 miles one way >Driven to work - Under 10 miles one way >Driven to work - Over 10 miles one way >Business Use >

Driver Information

Driver #1

Driver Name Age Years Licensed License Number Step Rating
Driver's Sex Male Female
Marital Status Single Married

Driver #2

Driver Name Age Years Licensed License Number Step Rating
Driver's Sex Male Female
Marital Status Single Married


Please list all accidents (including not-at fault accidents) and violations for the last 3 years:

Coverages

Liability Limit - Bodily Injury $15,000 per person, $30,000 each accident >$25,000 per person, $50,000 each accident >$50,000 per person, $100,000 each accident >$100,000 per person, $300,000 each accident >$250,000 per person, $500,000 each accident >
Property Damage $5,000 each accident >$10,000 each accident >$25,000 each accident >$50,000 each accident >$100,000 each accident >

Tort Option Full > Limited >



Uninsured/Underinsured Motorists Limit None > $15,000 per person, $30,000 each accident >$25,000 per person, $50,000 each accident >$50,000 per person, $100,000 each accident >$100,000 per person, $300,000 each accident >
Stack Uninsured/Underinsured Motorists Coverage Yes No

Comprehensive Coverage

Vehicle #1 No Coverage >$100 deductible >$200 deductible >$250 deductible >$500 deductible >$1,000 deductible >
Vehicle #2 No Coverage >$100 deductible >$200 deductible >$250 deductible >$500 deductible >$1,000 deductible >

Collision Coverage

Vehicle #1 No Coverage >$250 deductible >$500 deductible >$1,000 deductible >
Vehicle #2 No Coverage >$250 deductible >$500 deductible >$1,000 deductible >

Include Coverage for Towing & Labor ? Yes No
Include Rental Reimbursement Coverage? Yes No

Do any of your vehicles have airbags?

Vehicle #1 None > One >Two >
Vehicle #2 None > One >Two >

ABS Brakes ? Vehicle #1 Vehicle #2
Automatic Seat Belts ? Vehicle #1 Vehicle #2

Additional Information

Do you currently have insurance? YesNo
What is the expiration date of your current policy?


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