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Economy Insurance Agency, Inc.
Quote Form

By completing the following form, we can find out if you're paying
too much for your auto insurance and suggest alternatives.
In order to get the most accurate quote, please complete
as much information as possible.

You must include your e-mail address and complete
steps 1-3 in order to receive a quote.

click here to print this form

 
STEP 1: Driver #1
Complete the following information about yourself.
Full Name:
Home Telephone:
E-mail:
Work Telephone:
Address:
Age/Date of Birth:
State/Zip:
Years Licensed:
MA License: Yes No
Has your license ever been suspended or revoked?
Suspended Revoked Both Neither
Any accidents, violations and/or comp losses?
STEP 2: Financial / Insurance background
Occupation:
Have you had insurance? Yes No
If you've had insurance, please fill out the following:
My insurance policy is: Active Cancelled
Insurance Company name:
How long have you had the policy?
How much did it cost?
Did you get a quote yet? Yes No
From who?
How much was the quote?
STEP 3: Policy Information
Compulsory Insurance
Limits / Deductible
Premium
Bodily Injury to Others:
$20,000 Per Person,
$40,000 Per Accident

Premium
Personal Injury Protection:

$8,000 Per Person
Yourself
Yourself & Household Members
DED:


Premium
Bodily Injury Caused by an Uninsured Auto: (Compulsory Limits $20,000-$40,000)
Per Person:
Per Accident:

Premium
Damage to Someone Else's Property:
(Compulsory Limit $5,000)
Per Accident:

Premium
Optional Insurance
Optional Bodily Injury to Others:
Guest occupant exclusion for motorcycles
Per Person:
Per Accident:

Premium
Medical Payments:
Per Person:

Premium
Collision ACV:
Waiver of Deductible
DED:

Premium
Limited Collision ACV:
DED:

Premium
Comprehensive ACV:
DED:

Premium
Substitute Transportation:
Max Per Day:
Maximum:

Premium
Towing & Labor:
Up To:
For Each Disablement

Premium
Bodily Injury Caused by an Uninsured Auto:
Per Person:
Per Accident:

Premium
Safe Driver Insurance Plan (SDIP):
Step #:
Premium Adj:

Premium
ESTIMATED TOTAL PREMIUM:
STEP 4: Vehicle #1
Complete the following information about your first vehicle.
Year:
Make:
Model:
VIN Number:
Plate Registration Number:
Estimated Annual Mileage:
Is the vehicle used for business Yes No
Do you qualify for any of the following discounts?
Driver Air Bag Passenger Air Bag Anti-Theft Device
STEP 5: Vehicle #2
Complete the following information about your second vehicle.
Year:
Make:
Model:
VIN Number:
Plate Registration Number:
Estimated Annual Mileage:
Is the vehicle used for business Yes No
Do you qualify for any of the following discounts?
Driver Air Bag Passenger Air Bag Anti-Theft Device
STEP 6: Additional Operators
Full Name:
Age/Date of Birth:
Years Licensed:
MA License: Yes No
Full Name:
Age/Date of Birth:
Years Licensed:
MA License: Yes No
STEP 7: Additional Questions or Comments
Enter questions/comments:

 
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