Contact Us at Rogers & Gray

AUTO QUOTE REQUEST FORM

Please fill out the form as completely as possible. Fields marked with an * are required. Your privacy is important so we will only use this information to contact you. No information will be sold.

Please be advised that coverage may not be bound nor amended by this e-mail message.

OWNER INFORMATION
Owner's Name(s)*    
Email Address*    
Mailing Address*    
Town*    
State*    
Zip Code*    
Phone Number*    
Street Address (if different)    
Town    
State    
Zip Code    
License numbers are encrypted for security.
Owner's Drivers License Number*    
State*    
Second Owner's Drivers License Number    
State    
       
DRIVER INFORMATION      
Please list all licensed household members and regular operators.
Please put an asterisk after the name of anyone who has their own MA auto policy.
License numbers are encrypted for security
       
Name 1*   Year First Licensed   License Number 1*    
 
Has this person had a canceled policy in the last 2 years?   Yes No  
Name 2   Year First Licensed License Number 2  
 
Has this person had a canceled policy in the last 2 years?   Yes No  
Name 3   Year First Licensed License Number 3  
 
Has this person had a canceled policy in the last 2 years?   Yes No  
Name 4   Year First Licensed License Number 4  
 
Has this person had a canceled policy in the last 2 years?   Yes No  
                   
VEHICLE INFORMATION      
Car 1                        
Year*   Make*   Model*   Principal*   Operator*  
Does it have any anti-theft devices? Yes No If Yes, Please Describe:
Does it have any special equipment? Yes No If Yes, Please Describe:
Car 2                
Year Operator Make     Model   Principal Operator
Does it have any anti-theft devices? Yes No If Yes, Please Describe:
Does it have any special equipment? Yes No If Yes, Please Describe:
Car 3                
Year Operator Make     Model   Principal Operator
Does it have any anti-theft devices? Yes No If Yes, Please Describe:
Does it have any special equipment? Yes No If Yes, Please Describe:
                       
COVERAGE    
We recommend and will quote the following limits/coverage:
Bodily Injury to Others Liability: $250,000 per person/$500,000 per accident
Property Damage Liability: $100,000
Medical Payments: $10,000
Uninsured Motorists: $250,000/$500,000
Underinsured Motorists: $250,000/$500,000
Collision: $500 deductible with waiver
Comprehensive: $500 deductible
Substitute Transportation: $30 per day/$900 maximum
Towing & Labor: $50 per disablement
   
Are any of these vehicles used for:    
Business? Yes No    
Transporting of others? Yes No    
   
Payment Type - choose one:    
Billing at home  
Electronic Funds Transfer (EFT)  
Payroll Deducted (if program is in place with employer)  
         Employer Name:
   
ALTERNATE QUOTE IF OTHER LIMITS DESIRED
Bodily Injury to Others Liability:
Property Damage Liability:
Medical Payments:
Uninsured Motorists:
Underinsured Motorists:
Collision:
Comprehensive:
Substitute Transportation: 
Towing & Labor:
 
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