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Please
fill out as much information as possible. If you have any questions
about this form or filing a claim, please contact
us.
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| Name: |
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| Address
(city, state, zip code): |
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| E-mail: |
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| Telephone: |
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| Fax:
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| Best
time to call: |
|
 |
| Year:
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| Make: |
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| Model: |
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| Vehicle
I.D. #: |
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| Annual
Mileage: |
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| Air
Bag or electric seatbelt? |
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| Anti-theft
device? |
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| Years
of driving experience: |
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| Driver
training? |
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| Do
all drivers have a Massachusetts drivers license? |
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| Please
list all tickets and/or accidents in the last six years, or SDIP step
if known: |
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| Please
list dates of birth and drivers license #'s for all operators (optional
for more accurate quote): |
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Coverage
Options:  |
| Part
1 - Bodily
Injury to others: |
$20,000/$40,000
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| Part
2 - Personal
Injury Protection: |
$8,000
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| Part
3 - Uninsured
Motorist: |
|
| Part
4 - Property
damage: |
$100,000
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| Part
5 - Optional
Bodily Injury: |
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| Part
6 - Medical
Payments: |
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| Part
7 - Collision
(deductible): |
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| Part
8 - Limited
Collision: |
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| Part
9 - Comprehensive
(deductible): |
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| Part
10 - Substitute
Transportation: |
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| Part
11 - Towing
and Labor: |
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| Part
12 - Underinsured
Motorist: |
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| |
Submitting an insurance quotation request
to Ellis Insurance Agency does not constitute a binding confirmation
of new or altered insurance coverage. Verbal or written confirmation
must be obtained from Ellis Insurance Agency to confirm binding or altering
coverage. |