First Name *

Last Name *

Email *

Home Phone

Work Phone

Address 1

Address 2

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip

Please choose how much liability coverage you would like for this quote. All limits shown in 1,000s per person/per accident.

Bodily Injury to Others:
 $20/40 $50/100 $100/300 $250/500 Other

Uninsured Motorists:
 $20/40 $50/100 $100/300 $250/500 Other

Property Damage:
 $50 $100

Medical Payments (per person):
 $5 $10 $25

Underinsured Motorists:
 $20/40 $50/100 $100/300 $250/500 Other

Please tell us about your vehicle.

Year

Make

Model

License Plate

VIN

Body Style
sedan, wagon, etc.

Contact me  I have additional vehicles. Please contact me.

Please tell us what type of coverage you would like for this vehicle.

Collision:
 Yes No


If yes, choose deductible
 $300 $500 $1000

Comprehensive:
 Yes No


If yes, choose deductible
 $300 $500 $1000

Substitute Transportation:
 None $15/day $30/day

Towing:
 None $25/disablement $50/disablement

What is the effective date of this vehicle's current Auto policy?(mm/dd/yyyy)

Where do you garage this vehicle?

City

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip

Air Bag:
 Yes No

Anti-theft Device:
 Yes No

Vehicle Recovery:
 Yes No

Miles Driven Annually

Please furnish the following information for the primary driver of this vehicle. If there are additional drivers for this vehicle, please check the appropriate checkbox below and we will contact you.

Driver Name

Date of Birth

Drivers License

StateALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Has this driver made any claims during the last six years?
 Yes No


If yes, please explain briefly.

Additional Drivers?
 Yes No

Please indicate which of the following apply to you:
 Employee of the Town of Lee, MA Employee of Schweitzer-Mauduit International - Lee Mills Member of Greylock Federal Credit Union Home/Auto Package (insuring both home and auto with us) Multi-car (insuring more than one vehicle)

We will reply with your customized insurance quotation by the close of the next business day. After delivery of your quote, we can at your request call you to answer any questions you may have.

Would you like us to call you within 3 days of delivering your quote?
 Yes No

If YES, when you like us to contact you?
 Phone between 8:30 - 4:30 M-F Phone between 9 - Noon Saturday