Anchor insurance, Inc.
30 Tremont Street • Duxbury, MA 02332
781-934-7114 local • 800-649-3000 toll free in MA. • 781-934-2717 fax

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

In a hurry? Simply fax us a copy of your existing auto policy coverage page.
We can give you a quote from that!

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)

Driver Information

14. How many drivers are in the household?

1 2 3 4
15. Last Name
16. First Name
17. Date of Birth (mm/dd/yy)
18. License Number
19. State Issued
20. Driver Training Yes No Yes No Yes No Yes No
21. How long have you been licensed to drive?

Vehicle Information

Number of vehicles to be quoted

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

39. 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.