Serving Massachusetts since 1983
GUARD INSURANCE AGENCY
(617)926-4000                                        Expert, friendly & helpful insurance services.    
Independent Insurance Agent


Auto Insurance Information Form
Personal Information
First Name: 
Last Name: 
Address: 
City:    State:    Zip: 
Current residential status: 
Town vehicle garaged at: 
Day Phone:    Cell Phone: 
Email: 

Vehicle Information
 Vehicle 1: 
Year: 
Make:     Model:   
VIN: 
Annual Mileage (estimated): 
Primary use of vehicle:  Personal  Business 
Alarm:  Yes  No 
 Vehicle 2: 
Year: 
Make:     Model:   
VIN: 
Annual Mileage (estimated): 
Primary use of vehicle:  Personal  Business 
Alarm:  Yes  No 

Coverages
 Liability Limits
High Protection:
  250,000/500,000  Bodily Injury
  100,000  Property Damage
  250,000/500,000  Under/Uninsured Motorist Bodily Injury
Yes 
Mid-level Protection:
  50,000/100,000  Bodily Injury
  100,000  Property Damage
  50,000/100,000  Under/Uninsured Motorist Bodily Injury
Yes 
State Recommended Protection:
  100,000/300,000  Bodily Injury
  100,000  Property Damage
  100,000/300,000  Under/Uninsured Motorist Bodily Injury
Yes 
Customize Liabilities Protection:  
Bodily Injury:         
Property Damage:  
Uninsured Motorist Liability:   
Underinsured Motorist Liability
Yes 
Prior Policy Limits  
Prior Policy Bodily Injury:   
 
 Reimbursements
Medical Payments:   Yes 
Loss of Use:             Yes 
Towing & Labor:  Yes 
 Deductibles
Comprehensive Deductible:   Yes 
Collision Deductible:             Yes 

Driver Information
Drivers licence:     State Issued:  
Year Licensed:   
Occupation: 
Do you currently have
auto insurance: 
Yes, in Massachusetts 
Yes, outside of MA - please complete Out of State section
No 

Additional Drivers
Name
Date of Birth
Relationship
Drivers License

Out of State - Information requested of drivers new to MA
Please list any traffic violations or accidents in the past 6 years.
Driver
Date
Violation
 
 

Discounts
Please select any discount that may apply.
 Auto Club Member:  Yes   If yes, please specify:  
 Driver is age 65 or older:  Yes 
 New Drivers have Drivers Education:  Yes 
 Use public transit:  Yes 
 Low Annual Mileage:  Yes 
 Auto restraints or air bags:  Yes 
 Vehicle Retrieval System:  Yes 
 Anti Theft Device:  Yes 
 Hybrid vehicle:  Yes 
 Multiple vehicles:  Yes 
 Do you have/need home insurance:  Yes 

Additional Comments

   


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