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207 Main Street, Marlborough MA 01752-3850
tel. (508) 485-3150, fax (508) 485-3612, email info@ceconaryinsurance.com

Automobile Quote
The quotes provided here are for Massachusetts only.
Fill out the form below to obtain a Massachusetts auto quote or call us at
(508)485-3150. All red fields are required. Be careful to include their information before submitting your form. You may add up to 4 drivers and 2 vehicles on this quote form. For additional vehicles or drivers, feel free to call us. Note this quote form is for supplying a quote only. No coverage is bound by completing this quote form.

For state of Massachusetts explanations of the coverages down in the "Insurance Coverages" section, click the "?" button next to the coverage. These help links connect you with the Massachusetts Division of Insurance website explanations of the various insurance coverages.
Vehicle(s) Registration Information Section
 The name and address to which the vehicle(s) is or will be registered:
Name:
Street:
City/State/Zip: / /
Home Phone: Work Phone:
Email Address:
Driver Information Section          Review Sections:
State Licensed: Driver 1
Driver 2
Driver 3
Driver 4
Years of Driving Experience: Driver 1
Driver 2
Driver 3
Driver 4
If less than 3 years, have you completed a course in Driver Training? Driver 1
Driver 2
Driver 3
Driver 4 
Drivers License Number: Driver 1 
Driver 2
Driver 3
Driver 4
Date of Birth Driver 1
Driver 2
Driver 3
Driver 4
Please check what applies to the driver:

 		 Driver 1 Over the age of 65
Purchased a monthly transit
      pass (at least 11 months)
Driver 2 Over the age of 65
Purchased a monthly transit       pass (at least 11 months)
Driver 3 Over the age of 65
Purchased a monthly transit
      pass (at least 11 months)
Driver 4 Over the age of 65
Purchased a monthly transit
      pass (at least 11 months)
Has driver had any at-fault accidents or moving violations in the past six (6) years? Driver 1
Driver 2
Driver 3
Driver 4
If yes, please give a brief description:

 Driver 1
Driver 2
Driver 3
Driver 4
Vehicle Information Section          Review Sections:
Year Vehicle 1
Vehicle 2
Make Vehicle 1
Vehicle 2
Model
(Please be as specific as possible. ie. Honda Accord LX, 4 door)		 Vehicle 1
Vehicle 2
City Primarily Garaged: Vehicle 1
Vehicle 2
Please check all that apply to this vehicle.    
Airbags Vehicle 1
Vehicle 2
Automatic Seatbelts Vehicle 1
Vehicle 2
Drive less than 5,000 miles per year Vehicle 1
Vehicle 2
Drive between 5,000 miles and 7,500 miles per year Vehicle 1
Vehicle 2
Antitheft device (Alarm) Vehicle 1
Vehicle 2
Vehicle Recovery System (LoJack) Vehicle 1
Vehicle 2
Insurance Coverages Section          Review Sections:
Compulsory Insurance (Mandatory)

1. Bodily Injury to Others:

 Vehicle 1 $20,000 per person / $40,000 per accident
Vehicle 2 $20,000 per person / $40,000 per accident

2. Personal Injury Protection:

 Vehicle 1 $8,000 per person
Vehicle 2 $8,000 per person

3. Bodily Injury caused by uninsured auto:

 Vehicle 1
Vehicle 2
4. Damage to someone else's property: Vehicle 1
Vehicle 2

Optional Insurance
5. Optional Bodily Injury To Others: Vehicle 1
Vehicle 2
6. Medical Payments: Vehicle 1
Vehicle 2
7. Collision Coverage/ Deductible: Vehicle 1
Vehicle 2
8. Limited Collision: Vehicle 1
Vehicle 2
9. Comprehen-sive Coverage: Vehicle 1
Vehicle 2
10. Substitute Transportation: Vehicle 1
Vehicle 2
11. Towing and Labor: Vehicle 1
Vehicle 2
12. Bodily In-jury caused by underinsured: Vehicle 1
Vehicle 2
    End of Form                          Review Sections:
Select Response Method, then
click the Submit button below
Response Method
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          Fax Number:
          Mailing Address: Street:
  City/State/Zip: / /

How did you hear of us?     Other:

Comments:


         

We will send your quote promptly.
Thank you for considering C. E. Conary Insurance!

Copyright 2005. All Rights Reserved.


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