MyPolicy.com - Personal Insurance - Automobile

Section One - Personal Information

Name:

Address:

City:

State:Massachusetts Only

Zip:

Country:

Telephone:

Fax:

E-Mail:

Section Two - Vehicle Description

Vehicle One

Year, Make, and Model

Specific Model (i.e. XLT, GL, LS):

Vehicle Identification Number (VIN):

Number of Air Bags

Vehicle equipped with automatic seat belts?Yes No

Vehicle equipped with a car alarm?Yes No

If yes, indicate alarm brand:

Vehicle Two

Year, Make, and Model

Specific Model (i.e. XLT, GL, LS):

Vehicle Identification Number (VIN):

Number of Air Bags

Vehicle equipped with automatic seat belts?Yes No

Vehicle equipped with a car alarm?Yes No

If yes, indicate alarm brand:

Section Three - Driver Information

Driver One

Name

Date of Birth

Years Licensed

License Number

License State

What is your MA SDIP step?

Driver Two

Name

Date of Birth

Years Licensed

License Number

License State

What is your MA SDIP step?

Please list all accidents (including not-at-fault accidents) and violations for the last 3 years:

Please provide the names, dates of birth and license numbers of all licensed drivers living at the residence:

Are you a member of any of the follwoing organizations:

AAA: Yes No

Boston College Alumni Association: Yes No

Massachusetts Certified Public Accountant Association: Yes No

If you are moving to Massachusetts, please obtain an actual copy of your out-of-state driving record in order to be eligible for any MA credit points.

Section Four - Coverages

Required Coverage

Liability Limits - Bodily Injury

Property Damage

Uninsured/Underinsured Motorists Limits

Optional Coverage - Vehicle One

Comprehensive

Collision

Waiver of Deductible Yes No

Substitute Transportation

Towing

Optional Coverage - Vehicle Two

Comprehensive

Collision

Waiver of Deductible Yes No

Substitute Transportation

Towing vehicle

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