Application For Massachusetts Motor Vehicle Insurance Form - 2009
ADVERTISEMENT
1
2APPLICATION FOR MASSACHUSETTS MOTOR VEHICLE INSURANCE
PRODUCER
CODE:
APPLICANT'S NAME, RESIDENTIAL ADDRESS AND ZIP
PHONE:
BINDER/POLICY#:
EFFECTIVE DATE
EXPIRATION DATE
MAIL ADDRESS
(IF DIFFERENT)
COMPANY USE
PAYMENT PLAN
DEPOSIT PREMIUM
DIRECT BILL
AGENCY BILL
$
COVERAGE
INFORMATION:
Massachusetts
Law
requires
that
if
a
company
elects
to
provide
Compulsory
Insurance
Coverage
(Parts
1,2,3,4),
it
must
also
offer
the
following
Optional
Coverages:
Optional
Bodily
Injury
to
Others,
Bodily
Injury
Caused
by
An
Uninsured Auto,
Bodily
Injury
Caused
By
An
Underinsured
Auto
at
limits
up
to
$35,000
each
person,
$80,000
each
accident,
Medical
Payments
Coverage
up
to
$5,000,
Collision,
Limited
Collision,
Comprehensive
and
Substitute
Transportation.
However,
Part
7,
Collision,
Part
8,
Limited
Collision,
and
Part
9,
Comprehensive
coverages
may
be
refused
or
canceled
in
certain
situations
as
provided
for
in
the
law.
Part 11, Towing and Labor Coverage is available at the option of the Company.
COVERAGES: PARTS 1-12
AUTO 1
AUTO 2
COMPULSORY INSURANCE
LIMITS/DEDUCTIBLE
PREMIUM
LIMITS/DEDUCTIBLE
PREMIUM
1. BODILY INJURY TO OTHERS
$20,000 PER PERSON/$40,000 PER ACCIDENT
$
$20,000 PER PERSON/$40,000 PER ACCIDENT
$
$8,000 PER PERSON
YOURSELF
$8,000 PER PERSON
YOURSELF
2. PERSONAL INJURY PROTECTION
$
$
YOURSELF & HOUSE-
YOURSELF & HOUSE-
$
DED
$
DED
HOLD MEMBERS
HOLD MEMBERS
3. BODILY INJURY CAUSED BY AN
$
PER PERSON
$
PER PERSON
UNINSURED AUTO (COMPULSORY
$
$
LIMITS $20,000/$40,000)
$
PER ACCIDENT
$
PER ACCIDENT
4. DAMAGE TO SOMEONE ELSE'S
PROPERTY
$
PER ACCIDENT
$
$
PER ACCIDENT
$
(COMPULSORY LIMIT $5,000)
OPTIONAL INSURANCE
5. OPTIONAL BODILY INJURY TO
$
PER PERSON
$
PER PERSON
OTHERS
$
$
$
PER ACCIDENT
$
PER ACCIDENT
6. MEDICAL PAYMENTS
$
PER PERSON
$
$
PER PERSON
$
WAIVER OF
WAIVER OF
7. COLLISION
ACV
$
DED
$
$
DED
$
DEDUCTIBLE
DEDUCTIBLE
8. LIMITED COLLISION
ACV
$
DED
$
$
DED
$
$100 GLASS
$100 GLASS
9. COMPREHENSIVE
ACV
$
DED
$
$
DED
$
DEDUCTIBLE
DEDUCTIBLE
10. SUBSTITUTE TRANSPORTATION
UP TO $
$
$
A DAY, MAXIMUM $
$
A DAY, MAXIMUM $
11. TOWING AND LABOR
UP TO $
FOR EACH DISABLEMENT
$
$
FOR EACH DISABLEMENT
$
$
PER PERSON
$
PER PERSON
12. BODILY INJURY CAUSED BY AN
$
$
UNDERINSURED AUTO
$
PER ACCIDENT
$
PER ACCIDENT
MERIT RATING PLAN
PREMIUM ADJUSTMENT
$
PREMIUM ADJUSTMENT
$
GUEST OCCUPANT EXCLUSION FOR
PREMIUM*
$
PREMIUM*
$
MOTORCYCLE
TOTAL PREMIUM
$
PLACE OF PRINCIPAL GARAGING - AUTO 1:
AUTO 2:
VEHICLE INFORMATION
STREET ADDRESS,CITY OR TOWN ZIPCODE
VEHICLE COST
MAKE, MODEL AND,
GROSS VEHICLE
MILES AUTO
REGISTRATION
DATE OF
VEHICLE IDENTIFICATION
NEW OR MC
# YEAR
ODOMETER
WEIGHT RATING
WAS DRIVEN IN
AVERAGE
PLATE NUMBER
IF MOTORCYCLE, CC
PURCHASE
NUMBER
READING
FOR VAN OR PICK-UP
RETAIL VALUE
PAST 12 MOS
AIR BAG/
VEHICLE
LEASED
ANTI-
#
SECURED LENDER
AND/OR
LESSOR
PASSIVE
RECOVERY
THEFT
AUTO
(Please include name and address)
SEAT BELT
SYSTEM
(YES/NO)
(YES/NO)
(YES/NO)
(YES/NO)
NOTICE: Evidence of installation of an anti-theft device or a vehicle recovery system is required to receive a discount for Part 9, Comprehensive.
If
your
auto
is
not
equipped
with
an
anti-theft
device
or
a
vehicle
recovery
system
and
your
auto
is
on
the
High-Theft Vehicle
List furnished
with
this application,
you may be charged an Extra-Risk rate for Part 9, Comprehensive.
DRIVER INFORMATION: Furnish information for the applicant and each individual who customarily operates the auto(s) whether or not a household member.
Your failure to list a household member or any individual who customarily operates your auto may have very serious consequences.
DATE
DRIVER
CURRENT DRIVER'S LICENSE #/LICENSED STATE
% OF USE
#
DATE OF
FIRST LICENSED
MERIT
If licensed in another state or country within the last 6 years,
TRAIN
OPERATOR NAME
BIRTH
also indicate the state or country and the license number.
AUTO AUTO
AUTO AUTO
RATING
MOTOR
MASS
OTHER
POINTS
1
2
3
4
Y/N
CYCLE
1
2
3
4
NOTICE: It is a crime to knowingly provide false or fraudulent information for the purpose of defrauding an insurance company. If you or someone else on your behalf knowingly gives
us
false,
deceptive,
misleading or
incomplete
information
in
this application
and
if
such
false,
deceptive
misleading or
incomplete
information
increases our
risk of
loss, we
may
refuse
to
pay
claims under
any
or
all
of
the
Optional
Insurance
Parts and
we
may
cancel
your
policy.
Such
information
includes
the
description
and
the
place
of garaging of the vehicle(s) to be insured, the names of all household members and customary operators required to be listed and the answers given above for all listed operators.
You must notify us of changes that have occurred prior to the renewal of this policy and during the policy period. We may also limit our payments under Part 3 and Part 4.
We
will not
pay
for a
collision or
limited
collision loss for an
accident
which
occurs while
your
auto
is
being operated
by
a
household
member
who
is
not
listed
as
an
operator
on
your
policy.
Payment
is
withheld
when
the
household
member,
if
listed,
would
require
the
payment
of
additional
premium
on
your
policy because the household member would be classified as an inexperienced operator or would require payment of additional premium on your policy under the Merit Rating Plan.
PLEASE CONTINUE AND COMPLETE INFORMATION ON REVERSE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal