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Contact Information
Name *
Address
City, State, Zip
Phone
Fax
Email *
Best Contact Method
Email
Phone
Fax
UsMail
Best Time to Call
Current Insurance
Company Name
Expiration Date
Annual Premium
Vehicle(s)
Vehicle 1
Vehicle 2
Year
Make
Model
VIN
Garage Location
Odometer Reading
Annual Mileage
Business Use
Age 65 or Older
Air Bags
Automatic Seatbelts
Anti-Theft Device (Alarm)
Vehicle Recovery System (Lojack)
Public Transit Pass (11 months)
Accident Forgiveness
Good Student Discount
Student Away at School
Driver(s)
List all licensed drivers in your household.
Name on License
Date of Birth
License Number
State
Date Licensed
Driver
Training
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Coverages
Part 1 - Bodily Injury To Others
20/40
Part 2 - Personal Injury Protection
0
100
250
500
1,000
2,000
4,000
8,000
Part 3 - Bodily Injury By Uninsured Motorist
20/40
20/50
25/50
25/60
30/60
30/70
35/80
50/50
50/100
100/100
100/150
100/200
100/300
100/500
200/200
200/300
200/400
200/500
250/500
300/300
300/500
100/300
500/500
500/1000
Part 4 - Property Damage
50,000
100,000
150,000
200,000
250,000
300,000
400,000
500,000
Part 5 - Optional Bodily Injury
No Coverage
20/40
20/50
25/50
25/60
30/60
30/70
35/80
50/50
50/100
100/100
100/150
100/200
100/300
100/500
200/200
200/300
200/400
200/500
250/500
300/300
300/500
100/300
500/500
500/1000
Part 6 - Medical Payments
No Coverage
5,000
10,000
15,000
20,000
25,000
50,000
100,000
Part 7 - Collision Deductible
No Coverage
300
500
1,000
2,000
Part 8 - Limited Collision
No Coverage
0
300
500
1,000
2,000
Part 9 - Comprehensive Deductible
No Coverage
300
500
1,000
2,000
Part 10 - Substitute Transportation
No Coverage
15/day to 450 max
30/day to 900 max
45/day to 1,350 max
100/day to 3,000 max
Part 11 - Towing & Labor
No Coverage
50/incident
100/incident
Part 12 - Bodily Injury By Underinsured Motorist
No Coverage
20/40
20/50
25/50
25/60
30/60
30/70
35/80
50/50
50/100
100/100
100/150
100/200
100/300
100/500
200/200
200/300
200/400
200/500
250/500
300/300
300/500
100/300
500/500
500/1000
Disclaimer
- We will provide an estimated quote based on the information you provide. Actual premiums may vary due to additional or updated data received during the final underwriting process. A quote does not provide or guaranty insurance coverage. Insurance coverage can only be bound by an authorized agent upon receipt of down payment and signed application.
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Phone (MA): 781-767-2400
Fax: 781-767-0790
E-mail:
Jim@holbrookinsurance.com
paul@holbrookinsurance.com
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Holbrook Insurance Center, INC.
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