92 High Street
Danvers, MA 01923
Tel 978-750-0044
Fax 978-750-8808



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Request Auto Insurance Quote

IMPORTANT! Please Read Before Completing

By completing and submitting this form you agree that no coverage is bound and no policy is in effect until you are contacted by one of our representatives.  All information submitted is held in the strictest confidence and is only gathered for the purposes of providing you an insurance quote. To provide the most accurate quote possible please complete all areas that apply.

Massachusetts Auto Quote

 Name  
 Street Address  
 Street Address  
 City, State, Zip  
 Phone Number   Home    Work 
 Email        
 Current residence is:  
 Do you have insurance on your vehicle(s) now?  
      If no, when did your last policy expire?  
      If yes, what company?  
      If yes, what are your current liability limits?  
 Driver Information
 Driver #1
 Name  
 Drivers License No.  
 Date of Birth  
 Marital Status  
List all citations received in the past 3 years (Please include non-moving violations) and if any driver has had his/her driver's license suspended or revoked, or any major violations during the past 5 years?  
List all accidents driver was involved in.  
 Driver #2
 Name  
 Drivers License Number  
 Date of Birth  
 Marital Status  
List all citations received in the past 3 years (Please include non-moving violations) and if any driver has had his/her driver's license suspended or revoked, or any major violations during the past 5 years?  
 List all accidents that driver was been involved in.  
 Driver #3
 Name  
 Drivers License Number  
 Date of Birth  
 Marital Status  
List all citations received in the past 3 years (Please include non-moving violations) and if any driver has had his/her driver's license suspended or revoked, or any major violations during the past 5 years?  
 List all accidents that driver was involved in.  
Driver #4
 Name  
 Drivers License Number  
 Date of Birth  
 Marital Status  
List all citations received in the past 3 years (Please include non-moving violations) and if any driver has had his/her driver's license suspended or revoked, or any major violations during the past 5 years?  
List all accidents that driver was involved in.  
 Vehicle Information
 Vehicle #1
 Year, Make, Model  Year Make Model
 Vehicle ID Number  
 Body style  
 How is vehicle primarily used?  
If Business, describe type of business  
If Commute, how many miles one way?  
 Select coverage and limits below
 Liability  
 Un(der)insured Motorist   Will Match Liability Selection
 Medical/ Personal Injury Protection   Will Match Liability Selection
 Comprehensive  
 Collision  
 Towing  Company Will Provide Limits
 Rental Reimbursement  Company Will Provide Limits
 Vehicle #2
 Year, Make, Model  Year Make Model
 Vehicle ID Number  
 Body style  
 How is vehicle primarily used?  
If Business, describe type of business  
If Commute, how many miles one way?  
 Select coverage and limits below
 Liability  
 Un(der)insured Motorist   Will Match Liability Selection
 Medical/ Personal Injury Protection   Will Match Liability Selection
 Comprehensive  
 Collision  
 Towing  Company Will Provide Limits
 Rental Reimbursement  Company Will Provide Limits
 Vehicle #3
 Year, Make, Model  Year Make Model
 Vehicle ID Number  
 Body style  
 How is vehicle primarily used?  
If Business, describe type of business  
If Commute, how many miles one way?  
 Select coverage and limits below
 Liability  
 Un(der)insured Motorist   Will Match Liability Selection
 Medical/ Personal Injury Protection   Will Match Liability Selection
 Comprehensive  
 Collision  
 Towing  Company Will Provide Limits
 Rental Reimbursement  Company Will Provide Limits
 Vehicle #4
 Year, Make, Model  Year Make Model
 Vehicle ID Number  
 Body style  
 How is vehicle primarily used?  
If Business, describe type of business  
f Commute, how many miles one way?  
 Select coverage and limits below
 Liability  
 Un(der)insured Motorist   Will Match Liability Selection
 Medical/ Personal Injury Protection   Will Match Liability Selection
 Comprehensive  
 Collision  
 Towing  Company Will Provide Limits
 Rental Reimbursement  Company Will Provide Limits
 Please use the space below to add comments regarding any special circumstances or coverage needs

 

Contact Us
For information about Lynch Insurance please contact:
William Lynch
Customer Service
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