AMERICAN INSURANCE AGENCY

Auto Insurance Quote Form

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

American Insurance Agency
314 Main Street unit 205

Wilmington,MA 01887
978-657-0209

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
Driver's Sex Male Female
Marital Status Single Married

Driver #2

Driver Name Years Licensed License Number
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 $20,000 per person, $40,000 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 >





Uninsured/Underinsured Motorists Limit None > $20,000 per person, $40,000 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 >

Comprehensive Coverage

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

Collision Coverage

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

Additional Information

Do you currently have insurance? YesNo
Was your insurance cancelled anytime in the last 12 months for non payment?


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