Webber & Grinnell Automobile Insurance

Automobile Insurance Quote Form

Car Insurance Rocks At Webber & Grinnell!
Our job is to make sure you get the best possible coverage for the lowest possible cost!

For a quick quote, simply complete the following information and see how much we can save you! For an even faster quote, you can fax a copy of your existing policy to 413-586-6481. If you have questions about Mass Auto Insurance Reform or anything else, give us a call at 413-586-0111.

For Western Massachusetts Residents
(or Out-of-state Residents Moving to Western Massachusetts)


Name (First, Middle, Last):
Address:
City:	Zip: State: MA
Email Address:
Phone:	Work #: Ext: Home #:
Best way to contact:	E-mail Phone
Best time:	Morning Afternoon Evening

Driver Information
Please list all licensed household members.


Name	Date of Birth (Required)	License #	State	No. of Yrs. Driving
1.
2.
3.
4.

Vehicle Information


	Vehicle #1	Vehicle #2	Vehicle #3
Year
Make
Model/TYPE
Mass Plate or Vehicle ID Number
Anti-Theft Device

Liability Coverage

All vehicles will be quoted at $100,000 per person/ $300,000 per accident for Optional Bodily Injury (your liability for injury to others including guests in your vehicle), Uninsured & Underinsured Motorist and with Property Damage at $100,000 unless otherwise requested (see additional comments).

Optional Coverage Selections for your Vehicle


	Vehicle #1	Vehicle #2	Vehicle #3
Collision
Comprehensive
Towing & Labor
Substitute Transportation
Substitute Transportation	(Pays for rental coverage if your vehicle is in an accident)

Additional Discounts You May Be Eligible For:


	YES	NO
Motor Club / AAA Member
Hybrid Vehicle
Advanced Driver Training
Good Student
(Inexperienced operator on Dean's List - B or better grade point average)
Student Away at School
(Inexperienced operator at a school more than 100 miles away)
Account Credit
Do you currently own a home?
If YES, Homeowner's Company:
EFT (Electronic Funds Transfer)
Would you be interested in an automatic checkbook withdrawal payment plan? Savings up to 10%.

Additional Comments:

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Webber & Grinnell Insurance Agency
8 North King Street
Northampton, MA 01060

Phone: 413.586.0111
Toll-free: 800.416.0003
Fax: 413.586.6481

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