Name:
City Garaged:	State: Massachusetts Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Michigan Minnesota Misissippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Washington Washington D.C.
E-mail:	Zip Code:
Home Phone:	Work Phone:
Years Experience:	6 + 3 - 6 0 - 3	If less than 3 years, have you completed a course in Driver Training? No Yes
Date first licensed:	Date of Birth:
Do you own an insurance policy?:	Own Do not own If so,expiration date is:
	I will purchase insurance within the next <Select> 30 60 90 Other days.
Drivers License Number:

MAILING ADDRESS INFORMATION
Street: City: State: Zip:

VEHICLE INFORMATION
Year:  Make: Model:

Please check all that apply to you and/or your vehicle.

Airbags
Automatic Seatbelts
Drive less than 5,000 miles per year
Drive between 5,000 miles and 7,500 miles per year
Purchased a monthly transit pass (at least 11 months)
Antitheft device (Alarm)
Vehicle Recovery System (LoJack)
Over the age of 65

INSURANCE COVERAGES

Compulsory Insurance (Mandatory)

1. Bodily Injury to Others:	$20,000 per person / $40,000 per accident
2. Personal Injury Protection:	$8,000 per person
3. Bodily Injury caused by uninsured auto:	$20,000 per person / $40,000 per accident $25,000 per person / $50,000 per accident $35,000 per person / $80,000 per accident $50,000 per person / $100,000 per accident $100,000 per person / $300,000 per accident $250,000 per person / $500,000 per accident
4. Damage to someone else's property:	$5,000 $10,000 $25,000 $50,000 $100,000
Optional Insurance
5. Optional Bodily Injury To Others:	$20,000 per person / $40,000 per accident $25,000 per person / $40,000 per accident $25,000 per person / $50,000 per accident $35,000 per person / $80,000 per accident $50,000 per person / $100,000 per accident $100,000 per person / $300,000 per accident $250,000 per person / $500,000 per accident
6. Medical Payments:	No Coverage $5,000 per person $10,000 per person $15,000 per person $20,000 per person $25,000 per person
7. Collision Coverage/ Deductible:	No Yes
8. Limited Collision	Yes No
9. Comprehensive Coverage:	Yes No
10. Substitute Transportation:	No Coverage $15 per day $30 per day
11. Towing and Labor:	No Coverage $25 per incident $50 per incident
12. Bodily Injury caused by underinsured:	$20,000 per person / $40,000 per accident $25,000 per person / $50,000 per accident $35,000 per person / $80,000 per accident $50,000 per person / $100,000 per accident $100,000 per person / $300,000 per accident $250,000 per person / $500,000 per accident

Have you had any at-fault accidents or moving violations in the past six (6) years?

No Yes

If you have any questions or comments please state them here:

QUOTES ARE FOR MASSACHUSETTS ONLY!

 You will receive your quote by E-mail soon.

Home of.. Vellucci Insurance Agency
657 Cambridge St. - Cambridge MA 02140
Tel: 617-492-4150 - Fax: 617-492-0139