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Please complete the following questionnaire completely, and the mail or submit it when finished. Thank you. |
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If different from mailing address, please explain:
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How would you prefer that we contact you and at what general time?
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Do any of the vehicles have anti-theft devices? If YES, which vehicle(s) and what devices(s)?
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Low Mileage Discount: to determine eligibility, please list your current odometer reading by vehicle:
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Are any of the above vehicles a hybrid? If so, which?
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Are any of the above vehicles used on a farm? If so, which?
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Do any drivers have their own auto policy or are they listed on another policy? List the policyholder name, company and effective date.
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Are any drivers to be excluded from a vehicle? If so, which driver and which vehicle?
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Have any drivers attended driver training courses? If so, which drivers?
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Have any drivers attended Advanced Driver Training Courses? If so, which drivers and which courses?
Do you have certificate(s) of completion?
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Do any of the household drivers currently attend college? If so, who?
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Do any college attendees take a vehicle with them to school? If so, which vehicle?
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Where is the college located?
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Are any drivers college educators? If so, who are they and at which institution?
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Do any drivers qualify for a Good Student Discount? They must be on a dean’s list, honor roll, have a Grade B or better average, or must be in upper 20% of the class. Which driver(s) are they, and can you supply a report card?
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Many companies now offer Account Discounts. Please provide a copy of the declaration page(s) for the following policies if they are not currently written with Eldredge & Lumpkin:
Home:
Umbrella:
Boat:
Other (describe):
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Please list the insurance companies with which your home, umbrella, boat or business policies are placed if they are not with the Eldredge & Lumpkin Agency. Account credits may be offered.
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Do you belong to any motor club organizations? Please list club and membership number.
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Do any drivers use public transportation? If so, can you provide receipts?
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Massachusetts Coverage to be quoted: |
Coverage |
Recommended Limits |
Limits Requested |
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Pt 6: Medical Payments |
$10,000 |
$
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Pt 7: Collision Damage |
$500 Deductible |
$
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Pt 9: Comprehensive |
$500 Deductible |
$
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Pt 10: Substitute Transportation |
$45/day-$1,350 maximum |
$
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Pt 11: Towing and Labor |
$50 per disablement |
$
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Pt 12: Underinsured Motorist |
$250,000/$500,000 |
$
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Each company has its own enhanced coverage. We will offer the available coverage when a quote is supplied.
Please print and mail completed questionnaire to:
Eldredge & Lumpkin Insurance
697 Main St., Chatham, MA 02633
... or submit questionnaire by e-mail: |
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