Kunevich & Lau Insurance Agency

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Automobile Insurance Quote Form

Be careful to include all information before submitting your form.

You may add up to 2 drivers and 2 vehicles on this quote form.

For additional vehicles or drivers,

feel free to call us.

For state of Massachusetts explanations of the coverage's down in the

"Insurance Coverage's" 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 coverage's.

The quotes provided here are for Massachusetts only.

Driver Information Section
Name
Address
Address 2
City State    Zip
Home Phone Work Phone
Email
State Licensed
Years of Driving Experience
Drivers License Number
Date of Birth
Any at-fault accidents or moving violations in the past six (6) years Yes  No
If Yes, Please give a brief description
Additional Driver Information
Name
State Licensed
Years of Driving Experience
Drivers License Number
Date of Birth
Any at-fault accidents or moving violations in the past six (6) years Yes  No
If Yes, Please give a brief description
     
Vehicle Information Section
  Vehicle 1 Vehicle 2
Year
Make
Model
City Primarily Garaged
Please Check all that apply
Air Bags
Automatic Seatbelts
Drive Less than 5,000 miles per year
Drive between 5,000 and 7,500 miles per year
Anti-Theft Device (alarm)
Vehicle Recovery System (LoJack)
Insurance Coverage Section
Compulsory Insurance Vehicle 1 (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:
4. Damage to someone else's property:
Optional Insurance Vehicle 1
5. Optional Bodily Injury To Others:

6. Medical Payments:

7. Collision Coverage/ Deductible:

8. Limited Collision:

9. Comprehen-sive Coverage:

10. Substitute Transportation:

11. Towing and Labor:

12. Bodily In-jury caused by underinsured:

Compulsory Insurance Vehicle 2 (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:
4. Damage to someone else's property:
Optional Insurance Vehicle 2
5. Optional Bodily Injury To Others:

6. Medical Payments:

7. Collision Coverage/ Deductible:

8. Limited Collision:

9. Comprehen-sive Coverage:

10. Substitute Transportation:

11. Towing and Labor:

12. Bodily In-jury caused by underinsured:

Response Method
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Fax Number:
   
How did you hear of us?
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Comments:

 

      

 

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