Saltmarsh Insurance Agency - 24 Hour Quote Form


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Automobile Quote
The Quotes provided here are for Massachusetts only.

Fill out the form below to obtain a Massachusetts auto quote. All fields with an asterick are required. Be careful to include their information before submitting your form. This form is designed for quoting on one vehicle and one driver. For additional vehicles or drivers, feel free to call us.

For state of Massachusetts explanations of the coverages down in the "Insurance Coverages" 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 coverages.

The quotes provided here are for Massachusetts only.

Vehicle(s) Registration Information Section
The name and address to which the vehicle(s) is or will be registered:

Name:

Street:

City/State/Zip: / /

Home Phone: Work Phone:

Email Address:

Driver Information Section

State Licensed: Driver 1

Years of Driving Experience: Driver 1

If less than 3 years, have you completed a course in Driver Training? Driver 1

Drivers License Number: Driver 1

Date of Birth Driver 1

If you are a AAA member, what is your membership#: Driver 1

Please check what applies to the driver: Driver 1 Over the age of 65
Purchased a monthly transit pass(at least 11 months)

Has driver had any at-fault accidents or moving violations in the past six (6) years? Driver 1

If yes, please give a brief description: Driver 1

Vehicle Information Section

Year Vehicle 1

Make Vehicle 1

Model
(Please be as specific as possible. ie. Honda Accord LX, 4 door) Vehicle 1

City Primarily Garaged: Vehicle 1

Vehicle Identification #: Vehicle 1

Please check all that apply to this vehicle.

Airbags Vehicle 1

Automatic Seatbelts Vehicle 1

Drive less than 5,000 miles per year Vehicle 1

Drive between 5,000 miles and 7,500 miles per year Vehicle 1

Antitheft device (Alarm) Vehicle 1

Vehicle Recovery System (LoJack) Vehicle 1

Insurance Coverages Section

Compulsory Insurance (Mandatory)

1. Bodily Injury to Others: Vehicle 1 $20,000 per person / $40,000 per accident

2. Personal Injury Protection: Vehicle 1 $8,000 per person

3. Bodily Injury caused by uninsured auto: Vehicle 1

4. Damage to someone else's property: Vehicle 1

5. Optional Bodily Injury To Others: Vehicle 1

6. Medical Payments: Vehicle 1

7. Collision Coverage/ Deductible: Vehicle 1

8. Limited Collision: Vehicle 1

9. Comprehen-sive Coverage: Vehicle 1

10. Substitute Transportation: Vehicle 1

11. Towing and Labor: Vehicle 1

12. Bodily In-jury caused by underinsured: Vehicle 1

Response Method

I would like my quote sent to me via:

Fax Number:

Mailing Address: Street:

City/State/Zip: //

How did you hear of us? Other:

Comments: