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First Name
Last Name
Street Address
City
State
Zip Code
Day Time Phone
Cell/Other Phone
Email
Confirm Email
How would you like to be contacted?
Vehicle Information
1. Year?
2. Make, model and motorcycle CC?
3. Vehicle Identification Number?
4. Date of Purchase? (xx/xx/xx)
5. Was the vehicle?
6. Cost New?
7. Estimated annual mileage?
8. Odometer reading?
9. Air bag/passive seat belt? Yes No
10. Anti-theft? Yes No
11. Vehicle recovery system? Yes No
12. Leased Auto? Yes No
13. Bodily Injury Limits
14. Property Damage Limits
15. Collision
16. Fire, Theft and Glass Coverage? Yes No
17. Towing Coverage
18. Substitute Transporation
19. Secured Lender and/or Lessor?
Driver Information
1. Operator Name?
2. Date of birth? (xx/xx/xx)
3. Driver's License # / Licensed State?
If previously licensed in another state, indicate the state
and the state license number?
4. Date first licensed? (xx/xx/xx)
Massachusetts
Other
5. Approved driver training? Yes No
6. Owner? Yes No
7. Percent of use? %
8. During the last 6 years have you or any listed operator:
A. Been involved in any motor vehicle accident or been found guilty of any moving violation?
Yes No
B. Been assigned to an alchohol education program?
Yes No
C. Had two or more total fire or total theft losses?
Yes No
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