Personal Information
Name:
Address (city, state, zip code): 
E-mail: 
Telephone: 
Fax:
Best time to call:
Vehicle Information 
Year: 
Make: 
Model:
Vehicle I.D. #: 
Annual Mileage: 
Air Bag or electric seatbelt?
Anti-theft device?
Driver Information 
Years of driving experience: 
Driver training?
Do all drivers have a Massachusetts drivers license?
Please list dates of birth and drivers license #'s for all operators:
Coverage Options 
Part 1 - Bodily Injury to others: $20,000/$40,000
Part 2 - Personal Injury Protection: $8,000
Part 3 - Uninsured Motorist:
Part 4 - Property damage:
Part 5 - Optional Bodily Injury: 
Part 6 - Medical Payments:
Part 7 - Collision (deductible):
Part 8 - Limited Collision:
Part 9 - Comprehensive (deductible):
Part 10 - Substitute Transportation: 
Part 11 - Towing and Labor: 
Part 12 - Underinsured Motorist: 
Comments or additional pertinent information:

Submitting an insurance quotation request to Garrett-Lynch Insurance Agency does not constitute a binding confirmation of new or altered insurance coverage. Verbal or written confirmation must be obtained from Garrett-Lynch Insurance Agency to confirm binding or altering coverage.

  

If you have any questions or have trouble filling out this form please contact us. All hypertext descriptions of coverage options are from the Massachusetts State Division of Insurance.