Address

City, State, Zip

Vehicle Information
	Auto 1	Auto 2	Auto 3
Year
Make
Model
Type	2 Dr Coupe 4 Dr Sedan 3 Dr Hatch 5 Dr Hatch Pickup Sport/Utility Mini Van Other Van	2 Dr Coupe 4 Dr Sedan 3 Dr Hatch 5 Dr Hatch Pickup Sport/Utility Mini Van Other Van N/A	2 Dr Coupe 4 Dr Sedan 3 Dr Hatch 5 Dr Hatch Pickup Sport/Utility Mini Van Other Van N/A
Annual Mileage	1-5000 5001-7499 Over 7500	1-5000 5001-7499 Over 7500	1-5000 5001-7499 Over 7500
Comp	Refuse $300 $500 $1,000	Refuse $300 $500 $1,000 N/A	Refuse $300 $500 $1,000 N/A
Collision	Refuse $300 $500 $1,000	Refuse $300 $500 $1,000 N/A	Refuse $300 $500 $1,000 N/A
AirBag	yes	yes	yes
Alarm	yes	yes	yes

Driver Information
	Driver 1	Driver 2	Driver 3
Full Name
Date Of Birth
Year Licensed
Driver License #
Driver Training?	Yes	Yes	Yes

COVERAGE LIMITS
Since the first two coverages on your Massachusetts auto insurance policy are mandatory, we need not ask you to select limits for these coverages. These coverages are Bodily Injury ($20/$40 limit) and Personal Injury Protection ($8,000 limit).

Coverage #3 is Uninsured Motorist and it requires a minimum limit of $20/$40.

Coverage #4, Property Damage, is also mandatory, however you may select which limit you would like to carry. We recommend at least $100,000 coverage on Property Damage.

Property Damage	$100,000 $5,000 $10,000 $25,000 $50,000
Optional Bodily Injury	20/40 25/50 50/100 100/300 250/500
Optional Medical Payments	None $5,000 $10,000 $25,000
Optional Underinsured Motorist	Refuse 20/40 25/50 50/100 100/300 250/500
Optional Towing	Refuse $25 per tow $50 per tow
Optional Substitute Transportation (Rental)	Refuse $15/day $30/day
Are you eligible for a group discount?	None AAA-AutoClub Webster Credit Union Massachusetts Society of CPA's