Crosbie-Macdonald Insurance

To receive an auto insurance quote, please complete the following form.
NOTE: All applicable fields are required.

Name:
Date of Birth:
Address:
City:
State:		Zip:
Email:
Would you prefer a return quote by Email? YES NO
*Drivers License Number:

In order to provide an accurate quotation we must request a Motor Vehicle History from the Registry of Motor Vehicles. If you would like to receive a copy of this report please let us know.

SEND ME A COPY

*If you would prefer not to share your drivers license number we can produce a quotation based on a neutral Step 15 Safe Driver Credit. Because almost no one is a Step 15, your actual premium will likely vary up or down based on driving experience/history.

AUTO ONE	Year:
	Make:	Model:

AUTO TWO	Year:
	Make:	Model:

AUTO THREE	Year:
	Make:	Model:

AUTO FOUR	Year:
	Make:	Model:

Will the auto be garaged at your address above? YES NO
If NO, please provide City/Town where auto will be principally garaged:

COVERAGE SELECTIONS
LIMITS:
(You may find it helpful to refer to you present auto policy to determine the limits you presently carry)
Compulsory Coverage
Bodily Injury	$20,000/$40,000	Statutory minimum is $20,000/$40,000
Personal Injury Protection	$8,000	Statutory minimum is $8,000
Select Deductible		This is the amount you will pay before insurance pays
Uninsured Motorist		Statutory minimum is $20,000/$40,000
Property Damage		Statutory minimum is $5,000
Optional Coverage
Optional Bodily Injury
Medical Payments
Collision Deductible		Your lender or leasing company will require this coverage
Waiver	YES NO	This feature waives the deductible in accidents when you are less than 50% at fault
Comprehensive Deductible
Rental Reimbursement		Per day limit/maximum per loss
Towing		Amount per disablement
Underinsured Motorist
Discounts
Anti Theft: (please list any alarm, lojack or other device)

Multiple Autos: YES NO
Low Mileage: (please provide estimated annual mileage of vehicle)

Group Discounts: (Please contact Crosbie Macdonald to discuss available group discounts)
Please check that all required fields are completed and accurate before submitting the form.

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