AllMass / Fernekees Insurance Agency
One Stop Shopping for your Auto Insurance
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The following questions will allow us to provide you with the most accurate quote possible.  Please be assured that we do not share or sell personal information about you.
     
  Bold = Required field  
   
  First Name Last Name  
 
   
Address Line 1   Address Line 2    
     
  City State   Zip    
       
  Email Address   Phone  
     
     
Driver Information
     
 
Driver 1
      
Driver 2 (if applicable)
  
             
 
License Number
 
License Number
 
Date of Birth
 
Date of Birth
  Driving experience   Driving experience
  Any traffic violations or at fault accidents? Yes No   Any traffic violations or at fault accidents? Yes No
             
 
Driver 3 (if applicable)
  
Driver 4 (if applicable)
             
  Liscense Number     Liscense Number
  Date of Birth     Date of Birth
  Driving experience     Driving experience
  Any traffic violations or at fault accidents?   Yes No   Any traffic violations or at fault accidents? Yes No
               
 
Any Other Driver Information
 
       
 
Vehicle Information
       
 
Vehicle 1 - Description
  
Vehicle 2 - Description (if applicable)
  
             
  Year   Make   Year Make
     
 
Model
      
Model
 
 
   
 
           
 
Vehicle 1 - Coverages
  
Vehicle 2 - Coverage (if applicable)
           
  Part 1 - Bodily Injury to Others
Compulsory		   Part 1 - Bodily Injury to Others
Compulsory
   
           
  Part 2 - Personal Injury Protection
Compulsory		   Part 2 - Personal Injury Protection
Compulsory
   
             
  Part 3 - Bodily Injury Caused by an  Uninsured Motorist
Compulsory		   Part 3 - Bodily Injury Caused by an  Uninsured Motorist
Compulsory
   
             
  Part 4 - Damage to Someone Else's Property
Compulsory		   Part 4 - Damage to Someone Else's Property
Compulsory
   
             
  Part 5 - Optional Bodily Injury to Others   Part 5 - Optional Bodily Injury to Others
   
             
  Part 6 - Medical Payments per person)
Optional		   Part 6 - Medical Payments per person)
Optional
   
             
  Part 7 - Collision
Optional		   Part 7 - Collision
Optional
   
             
  Part 8 - Limited Collision
Optional		   Part 8 - Limited Collision
Optional
   
             
  Part 9 - Comprehensive
Optional		   Part 9 - Comprehensive
Optional
   
             
  Part 10 - Substitute Transportation
Optional		   Part 10 - Substitute Transportation
Optional
   
             
  Part 11 - Towing & Labor Optional   Part 11 - Towing & Labor Optiona
   
             
  Part 12 - Bodily Injury Caused by an Underinsured Vehicle Optional   Part 12 - Bodily Injury Caused by an Underinsured Vehicle Optional
   
             
 
Credit Eligibility
  
Credit Eligibility
             
  Does vehicle 1 have an alarm device? Yes  No   Does vehicle 1 have an alarm device? Yes  No
       
  If you answered yes, what kind of alarm is it?   If you answered yes, what kind of alarm is it?
   
           
  The Massachusetts Auto Insurance Policy allows up to FOUR vehicles per policy. If you own any other vehicles please fill-in the appropriate information here:
 
  Are you a AAA member? Yes  No  
   
  Have you been cancelled or nonrenewed in the last 12 months? Yes  No
         
  If your insured with us already let us know who your agent is, in order to direct your request accordingly?
 
     
  How did you hear about us?