Application For Massachusetts Motor Vehicle Insurance Form - 2009 Page 2
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2DRIVER INFORMATION (CONTINUED) -- Explain all "Yes" responses in the REMARKS Section. During the last six years have you or any listed operator:
D. BEEN CONVICTED OF VEHICULAR HOMICIDE, AUTO RELATED
A. BEEN INVOLVED IN ANY MOTOR VEHICLE ACCIDENT
YES NO
YES
NO
FRAUD, AUTO THEFT, OR DRIVING UNDER THE INFLUENCE
OR BEEN FOUND GUILTY OF ANY MOVING VIOLATION?
OF ALCOHOL OR DRUGS?
E. RECEIVED PAYMENT FROM AN INSURANCE COMPANY FOR
B. BEEN ASSIGNED TO AN ALCOHOL EDUCATION PROGRAM?
ANY COMPREHENSIVE CLAIM?
C. HAD TWO OR MORE TOTAL FIRE OR TOTAL THEFT
F. HAD YOUR LICENSE REVOKED OR SUSPENDED?
LOSSES?
LICENSE INFORMATION: Once you or the principal operator listed on this application become a resident of Massachusetts, you or the principal operator
must obtain a Massachusetts driver's license. A resident of another state may drive in Massachusetts with a currently valid license issued by the individual's
state of residence. A visitor from another country who is at least 18 years old and has a valid license issued by a country accepted by the Registrar of Motor
Vehicles (in accordance with the 1949 Road Traffic Convention or the 1943 Inter-American Automotive Traffic Convention) may legally drive in
Massachusetts for up to one year from the date of arrival in the United States. The failure by you or the principal operator to be properly licensed to operate
a motor vehicle in Massachusetts may result in the non-renewal of the automobile insurance policy. For information about the Massachusetts requirements
for driver's licenses, please consult the Registry of Motor Vehicle's website at
MERIT RATING INFORMATION If in the last six years any listed operator had a driver's license in the United States or certain countries whose record are
electronically available, we will obtain that official driving record(s), which will be used to assign merit rating points.
GENERAL INFORMATION -- Explain all "Yes" responses in the REMARKS Section; on Questions 3-8 include the auto number.
5. IS ANY AUTO USED TO TRANSPORT (To or From Work or School):
YES NO
1. DO YOU PRESENTLY OWE ANY MOTOR VEHICLE PREMIUM, PAYABLE
YES NO
A. FELLOW EMPLOYEES, PASSENGERS OR STUDENTS, FOR A FEE?
IN THE LAST TWELVE MONTHS?
B. PERSONS EMPLOYED BY YOU?
2. HAS YOUR AUTOMOBILE INSURANCE POLICY BEEN CANCELED OR NON-
6. IS ANY VAN OR PICK-UP EQUIPPED WITH CUSTOM FURNISHINGS OR
RENEWED FOR ANY REASON IN THE LAST THREE YEARS?
CUSTOM EQUIPMENT? (If Yes, You May Wish to Purchase Additional Coverage)
7. IS ANY AUTO EQUIPPED WITH ELECTRONIC EQUIPMENT PERMANENTLY
3. ARE ANY LISTED OPERATORS INCLUDED ON ANOTHER POLICY OR DO
INSTALLED BUT NOT IN LOCATIONS USED BY THE AUTO
THEY HAVE THEIR OWN MASSACHUSETTS PERSONAL AUTOMOBILE
MANUFACTURER FOR SUCH EQUIPMENT? (If You Wish to Purchase
POLICY? (LIST OPERATOR #, INSURANCE COMPANY, AND POLICY #)
Coverage For these Items, list Make, Model, Serial #, Amount of Ins. for Items).
8. IS ANY AUTO USED IN BUSINESS? (Type of Business)
4. IF A VEHICLE IS A MOTORCYCLE, HAS THE PRINCIPAL OPERATOR
COMPLETED AN APPROVED MOTORCYCLE RIDER TRAINING PROGRAM?
A. IF VAN/PICK-UP, IS IT USED TO DELIVER/TRANSPORT GOODS?
B. IS GROSS VEHICLE WEIGHT 10,000 POUNDS OR MORE?
(ATTACH COPY OF CERTIFICATE OR OTHER EVIDENCE OF COMPLETION)
ATTACHMENTS
9. IF ANY AUTO(S) TO BE INSURED IS TITLED WITH A SALVAGE TITLE ISSUED BY THE MASS REGISTRY OF
MOTOR VEHICLES, PLEASE INDICATE. (Salvage Title Vehicles Are Not Eligible for Coverage Parts 7, 8, or 9)
ANTI-THEFT DEVICE CERTIFICATE
AUTO 1
AUTO 2
APPRAISAL
10. IF ANY AUTO(S) LISTED ON THE APPLICATION IS CONSIDERED TO BE AN ANTIQUE AUTO AND YOU
APPROVED DRIVER TRAINING CERTIFICATE
WISH TO PURCHASE COVERAGE PARTS 7, 8, OR 9, ATTACH A COPY OF THE CURRENT APPRAISAL.
APPROVED MOTORCYCLE RIDER TRAINING CERT.
CUSTOMIZED EQUIPMENT EVIDENCE
11. IF THIS APPLICATION IS FOR A MOTORCYCLE, TRAILER OR RECREATIONAL VEHICLE, AN ANNUAL
POLICY WILL BE ISSUED UNLESS INDICATED BELOW:
OPERATOR EXCLUSION FORM
MOTORCYCLE ONLY- ISSUE MY POLICY TO EXPIRE AT 12:01 AM ON JANUARY 1ST AND DO NOT RENEW.
OUT-OF-STATE DRIVER RECORD
TRAILER OR
RECREATIONAL VEHICLE- ISSUE
MY
POLICY
TO
EXPIRE
AT 12:01
AM
ON
DECEMBER 1ST
PRE-INSURANCE FORM
AND DO NOT RENEW.
VEHICLE RECOVERY SYSTEM CERTIFICATE
REMARKS - IF ADDITIONAL SPACE IS REQUIRED, ATTACH ADDITIONAL SHEET(S) OF PAPER.
FAIR
CREDIT
REPORTING
ACT:
In
connection
with
your
application
for
insurance
and
as
part
of
our
normal
underwriting
procedure,
an
investigative
consumer
report
may
be
obtained,
including,
if
applicable,
information
as
to
character,
general
reputation,
personal
characteristics
and
mode
of
living.
This
information
is
obtained
through
personal
interviews
with
your
friends,
neighbors
and
associates.
Upon
written
request,
received
within
a
reasonable
time,
additional detailed information concerning the nature and scope of this investigation will be provided.
DECLARATIONS AND SIGNATURES
I DECLARE THAT ALL THE STATEMENTS CONTAINED IN THIS APPLICATION ARE COMPLETE AND TRUE TO THE BEST OF MY KNOWLEDGE AS OF THIS DATE. I
UNDERSTAND
THAT
THE
COMPANY
MAY
EXCHANGE
PAYMENT
OF
PREMIUM
INFORMATION
AND
ACCIDENT
OR
CLAIM
INFORMATION
WITH
OTHER
AUTOMOBILE INSURANCE COMPANIES.
Signature of Applicant
Date and Time
TO BE COMPLETED BY AGENT:
The information contained in this application is as told to me by the applicant and is true and complete to the best of my knowledge.
Signature of Agent
Date and Time
IF THIS APPLICATION IS BEING ELECTRONICALLY TRANSMITTED, THE FOLLOWING MUST ALSO BE COMPLETED:
I agree to be bound by this electronic record and it shall have the same legal force and effect as the written application.
Applicant's Name
2009
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