The Gaudreau Group.
 P.O. Box 1984 Boston Road
Wilbraham, MA 01095
413- 543-3534 local
800-750-3534 toll free
413-543-4153 fax

Massachusetts Commercial Auto Quote
We provide insurance coverage in Massachusetts only.
Sorry, other states not available.

1. Company Name

2. Contact Name

3. Mail Address

4. Street Address if different

5. City
 6. State
 7. Zip

8. Email

9. Work Phone / Ext.:

10. Fax

11. Best Time To Contact

12. Currently Insured? Yes NoIf No, proceed to Driver Information Question 15

13. If insured, list insurance carrier

14. Expiration Date (MM/DD/YY)

14a. Full description of your business (this will help us identify your insurance needs):

14b.Any auto claims in the past 5 years? Yes No

14c. Do you have any employees regularly use their personal vehicles for company business? Yes No

Driver Information

1 2 3 4
15. Last Name
16. First Name
17. Middle Initial
18. Date of Birth (mm/dd/yy)
19. License Number
20. State Issued

Vehicle Information

21. Number of vehicles to be quoted

1 2 3 4
22. Year (i.e. 1995)
23. Make
24. Model
25. Sub Model
26. Body Style
26a. List City/Town where garaged
27. VIN#
28. Gross Vehicle Weight (not required for cars)
29. Describe use of Vehicles
30. Snow Plowing Yes No Yes No Yes No Yes No
30a. If yes, do you plow for the state, city, or town? Yes No Yes No Yes No Yes No
31. Radius of Work Miles Driven
32. Cost of Vehicle New
33. Does vehicle have any customized equipment? (example, lettering, signs, tool box etc.) Yes No Yes No Yes No Yes No
33a. If yes to #33, please list
34. Optional Bodily Injury (choose one)
35. Property Damage to Someone Else's Property
36. Medical Payments
37. Un-insured Motorist Coverage (choose one)
38. Underinsured Motorist Coverage (choose one)
39. Optional Comprehensive Deductible (fire/theft/vandalism/glass coverage)
40. Optional Collision Deductible
41. Optional Loss of Use (Car Rental) Yes No
 Yes No
 Yes No
 Yes No
42. Optional Towing Yes No
 Yes No
 Yes No
 Yes No

43. Questions and/or Comments

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Important Note: Quotes will be based on the information provided. It is only a rate calculation and is not binding in any way. A full application must be completed and signed by the named insured.