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

1. Full Name

2. Address

3. Mail Address if different

4. City
 5. State
 6. Zip

7. Email

8. Home Phone

9. Work Phone / Ext.:

10. Fax

11. Best Time To Contact

12. Currently Insured? Yes No

13. Expiration Date (optional) (MM/DD/YY)

14. Have you had a Massachusetts driver's license for at least 6 years? Yes No

Driver Information

15. How many drivers are in the household?

1 2 3 4
16. Last Name
17. First Name
18. Middle Initial
19. Date of Birth (mm/dd/yy)
20. License Number
21. State Issued
22. Driver Training Yes No Yes No Yes No Yes No
23. How long have you been licensed to drive?
24. Any moving violations, DUI's or at-fault accidents in the past 6 years? Yes No Yes No Yes No Yes No

Vehicle Information

Number of vehicles to be quoted

1 2 3 4
25. Year (i.e. 1995)
26. Make
27. Model
28. Sub Model
29. Body Style
30. VIN#
31. Air Bags Yes No Yes No Yes No Yes No
32. Automatic Seat Belts Yes No Yes No Yes No Yes No
33. Anti-Theft
34. Vehicle Usage
35. If for business, describe how vehicle(s) are used in business
36. Annual Miles Driven (approximately)
37. Un-insured Motorist Coverage (choose one) (Part 3 of your existing policy)
38. Property Damage to Someone Else's Property (choose one) (part 4 of your existing policy)
39. Optional Bodily Injury Increased Limits (part 5 of your existing policy) (choose one)
40. Medical Payments (part 6 of your existing policy) (choose one)
41. Collision Deductible (part 7 of your existing policy) (choose one)
42. Comprehensive (fire/theft/vandalism/glass coverage) Deductible (part 9 of your existing policy) (choose one)
43. Substitute Transportation (Car Rental) coverage per day (part 10 of your existing policy) Yes No Yes No Yes No Yes No
43a. If Yes to #42, (choose one)
44. Towing (part 11 of your existing policy) Yes No Yes No Yes No Yes No
44a. If Yes to #43, (choose one)
45. Underinsured Motorist (part 12 of your existing policy)

46. 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.