Personal Auto Policy Questionnaire:
Please fill out and submit this form for your personal auto insurance quote. If you have any questions please feel free to at 781-893-3200. We will be happy to assist you in any way.

* indicates required field

* Name:

Date of Birth:

* Address:

* City:

* State:

* ZipCode:

* Phone:

* E-mail:

Massachusetts License Number:

If out of State/Country Drive, Social Security Number:

Is this the same address at which the vehicle(s)
being insured is/are garaged?

Yes

Vehicle(s):

Does/Do the vehicle(s) have an alarm?

Yes

If yes, What type of alarm:

Will there be any other regular/occasional operators?:

Yes

Are they license household members?

Yes

	Name	DOB	Lic #	State	Insurance
Driver 1:
Driver 2:
Driver 3:
Driver 4:

Is/Are the insured vehicle(s) used for business?:

Yes

Are you a AAA Member?:

Yes

Do you utilize MA Public Transportation on a regular basis?

Yes

Are you a member of the MSPCA?:

Yes

Are you interested in having your monthly payments
automatically deducted from your bank account?:

Yes

Why have you chosen to write this new policy with Stanton Insurance Agency? (check all that apply)

	Have a current policy w/ SIA			Previously insured w/ SIA

	Referred to SIA			Walk-In

	Family/Friend insured w/ SIA			SIA Advertising - Website, Yellow pages, Newspaper

	Other (please explain below)

Additional Comments:

* Date:

LIFE/BENEFITS/DISABILITY