Massachusetts Automobile Insurance

Renewal Questionnaire

If you've had changes in your life or are not sure if we have all the information we need; please complete the below questionnaire to provide us with the most up to date information. Changes in your life can impact auto insurance discounts your eligible for or coverage needs.

*First Name
Last Name:
*Address:
 
*City:
State:
*Zip:
Phone Number:
Cell Phone:
*E-mail:

Discounts and Savings opportunities
Let us know if the following have changed or apply to your situation to help us maximize your savings.

You have home, condo or renter insurance with another company:
Yes No
If yes, insurance co/agent


Your spouse has a separate auto policy:
Yes No


You're a member of a motor Club, i.e. AAA, Onstar, Sam's Club GM motor club, etc.:
Yes No
If yes, motor club name


Any driver listed on your policy has completed an approved Advanced driver Training program beyond required MA drivers ed:
Yes No
If yes, driver name


A high school or college student listed on your policy maintains a grade average of "B" or 3.0 or higher:
Yes No
If yes, student name


Any student at school over 100 miles from primary residence:
Yes No
If yes, student and school name


Is any vehicle driven less than 12,500 miles a year:
Yes No
If yes, indicate vehicle

Auto policy details

The garaging address for any auto is different from your residential address:
Yes No
If yes, indicate vehicle and address



You have a loan on a vehicle on your policy:
Yes No
If yes, indicate vehicle


A vehicle is used in business:
Yes No


You drive a company car or other vehicle on a regular basis:
Yes No


You have customized equipment installed on your vehicle:
Yes No


Years at current residence:

Package and special coverage options
Please indicate protection options you are interested in. Not all options are available with all insurance carriers that we represent.
Accident forgiveness: Yes No
Auto loan/lease gap coverage:
vehicle less than two years old		 Yes No
Disappearing deductible:
vehicle must have full coverage		 Yes No
New vehicle replacement value:
restrictions in number of years and term		 Yes No

Pet injury related to accident- up to $500:

 Yes No

Comments: Please provide any additional comments that will help us make sure you have the appropriate protection

Kerrigan, O'Malley & Bailey Insurance Agency takes the protection of information you share with us seriously. Law regulates the collection, use and disclosure of such information. For additional information please review our privacy policy.
Please note: Insurance coverage cannot be bound "without" a written binder from our office.