PO Box 406 - 190 Chauncy Street
Mansfield, MA 02048
Ph: (508) 339-2951
Fax: (508) 339-4811
Directions
Demello Professional Building
71 Main Street
Taunton, MA 02780
Ph: (508) 824-1386
Fax: (508) 822-3040
Directions
DRIVER INFORMATION

** Fields in red are required **

Name: Address:

City: State: Zip:

Country: Phone Number/Extension:

Fax Number: E-mail:


Comments, questions or suggestions?


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
City or Town where vehicle is principally garaged
Make of vehicle (Chevy, Honda, etc.)
Model of vehicle
(Malibu, Accord, etc.)
Body Style of vehicle
(sedan, van, wagon, etc.)
Year of vehicle
Vehicle I.D. Number
(VIN optional)
Number of miles driven each year
Number of Doors
Number of Airbags
Automatic Seat Belt



MANDATORY CONVERAGES
Bodily Injury to Others. 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 in the following box. Go to the "Optional Coverage" section below if you want additional bodily injury coverage.

Personal Injury Protection. This typically covers injuries to you and your passengers, regardless of who's at fault. This mandatory coverage is already selected for you in the following box. For additional coverage see optional "Medical Payment" coverage below.

Bodily Injury Caused by an Uninsured Auto. This typically covers you for bodily injury to you or your passengers by an uninsured vehicle.

Property Damage to Someone Else's Property. This typically covers you for accidents causing damage to another's property.


OPTIONAL CONVERAGES
Please fill out this section if you want "optional" coverages
Bodily Injury to Others. This is additional coverage for bodily injury to others.

Medical Payments.This typically covers injuries to you and your passengers, regardless of who's at fault.

Collision. This typically covers physical damage to your vehicle from an accident.
Coverage... Deductible...

Comprehensive. This typically covers all other physical damage to your vehicle (other than collision) including fire, theft, vandalism, and glass.
Coverage... Deductible...

Rental. This typically covers the cost to rent a vehicle while yours is disabled.

Towing & Labor.> This typically covers towing and labor charges for your disabled vehicle.

Bodily Injury Caused by an Underinsured Driver. This typically covers bodily injury to you or your passengers by underinsured drivers.

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Disclaimer: All quotes are computed to the best of our ability utilizing the the information provided by you. If the information provided is incomplete or incorrect, your actual quote may change. Thank You.
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