Cape Ann Insurance Agency, Inc. www.capeanninsurance.com

Massachusetts Personal Automobile Quote

* First Name

* Last Name

* Date of Birth
(mm/dd/yyyy)

* Year
First Licensed

* Driver
License #

* Street Number and Name

Apartment #

* City/State/Zip Code

Vehicle Information :

* Car 1 Year

* Make and Model

Reg or VIN #

Car 2 Year

Make and Model

Reg or VIN #

Coverage Options:

* Liability Coverage

Level 1, Basic: 50,000 per person/100,000 per accident

Level 2, Moderate: 100,000 per person/300,000 per accident

Level 3, Higher: 250,000 per person/500,000 per accident

* Physical Damage to
Your Car:

None: No collision, comprehensive or glass.

Limited: collision if at fault veh id'd; comprehensive with 500 ded.

Full: collision & comprehensive with 500 ded.

* Other limits (or higher/lower limits) are available: call for more information.

* Discounts

AAA Member

Have a Homeowner or Renters Insurance Policy

Drive less than 12,500 miles per year

None

If you have a Homeowners or Renters Insurance Policy,
with which company do you have coverage?

* Do you currently have insurance on this car?

Yes

If yes, please provide the name and number of
years with the current insurance company.

* Has your coverage been declined, cancelled
or non-renewed in the past three years?

Yes

If yes, please provide details.

Other Drivers:

Driver 2,
Name (First and Last)

Driver 2
Birthdate

Year 1st
Licensed

Driver 2
License #

Driver 3,
Name (First and Last)

Driver 3
Birthdate

Year 1st
Licensed

Driver 3
License #

Driver 4,
Name (First and Last)

Driver 4
Birthdate

Year 1st
Licensed

Driver 4
License #

* Please Provide Your Email Address

* Phone Number (optional)

Best Time to Contact

This is a quote only. In order for coverage to be in effect, approval of a completed application (including supplemental forms in some cases) and a deposit payment are required. In addition, we may be required to obtain an insurance credit score as part of the quoting and/or application process.

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Cape Ann Insurance Agency, 23 Dale Ave, Gloucester MA