King & Cushman Insurance & Financial Services, Northampton, MA


Personal Auto Insurance Quote Form

First Name: Last Name:  

Street:

City: State: Zip:

Phone: Fax Number:

Email:

Best Way to Reach you: Phone Fax Email

Driver Information

Name
Date of Birth
License #
State
No. of Yrs. driving
1.
2.
3.
4.

Vehicle Information
Vehicle 1
Vehicle 2
Vehicle 3
Year
Make
Model
VIN number
Estimated Annual Mileage

Anti-Theft Devices

Vehicle 1
Vehicle 2
Vehicle 3
Factory Installed Alarm Yes No Yes No Yes No
Etched Windows Yes No Yes No Yes No
Lojack Yes No Yes No Yes No

Liability Coverage

The coverage limit shown in the boxes below are our Minimum recommendations of coverage for you and your family. To choose other available coverage options, Please click on the drop down boxes.
Vehicle 1
Vehicle 2
Vehicle 3
Uninsured Motorist
per person/per accident
per person/per accident
per person/per accident
Property Damage
Optional Bodily Injury to Others
per person/per accident
per person/per accident
per person/per accident
Medical Payments
Underinsured Motorist
per person/per accident
per person/per accident
per person/per accident

Collision Coverage

The coverage limits in the boxes below are our recommendations for coverage. To select other available options, please click on the drop-down boxes.
Vehicle 1
Vehicle 2
Vehicle 3
Collision
Comprehensive
Substitute Transportation
Towing & Labor

Additional Comments